HRSA 340B Peer-to-Peer (P2P) Program Application

v3
Please note: The online application must be completed in one session. Work cannot be saved halfway through the completion of the process. You may want to complete the essay questions in another program first and then paste them into the P2P application once complete.  Once you hit submit, you will not have the ability to make changes.  An email notification will be sent upon submission to the email provided at the bottom of the application.  A link will be provided in the email with the option to print.

 

Organization Information

Name of Organization as listed in the OPA database:    
Address Line 1:    
Address Line 2:    
City/Town:    
State:    
Zip Code:               340B ID#:    
Main Number:    
Organization Type:  
(Other Org. Type)    
     

Select the option(s) that best describe your organization’s pharmacy services

   
   
   
   
   
   
   
      
   
  Does your organization currently participate in the HRSA Patient Safety and Clinical Pharmacy Services Collaborative (PSPC)?
   
  Is your organization currently enrolled in the Prime Vendor Program (PVP)?
   
  Will you bill Medicaid for 340B purchased drugs?
   
  Does your organization employ a sliding fee scale?
   
  Does your organization serve both 340B and non 340B patients?
   
  Does your organization operate in a mix-used setting?
   
  Do providers at your clinic/hospital also provide care outside your organization?
   
  Select the type of inventory that your pharmacy employs:
   
  Hospitals Only  
  Is your hospital subject to the GPO prohibition?
  Is your hospital subject to the Orphan Drug Exclusion?
   
  How did you hear about the Peer-to-Peer Program/Application?  
 
   
Other:  
   

Organization Key Contact Person

Name:  
Title/Position:  
Email:     Phone:  
          

Secondary Contact Person

Name:  
Title/Position:  
Email:     Phone:  
          

Additional Staff Member (optional)

Name:
Title/Position:
Email: Phone:
          

Senior Leader 1 (ex. CEO, CFO, COO, CMO, etc.).

Name:  
Title/Position:  
Email:   Phone:  
          

Senior Leader 2 (ex. CEO, CFO, COO, CMO, etc.).  (optional)

Name:
Title/Position:
Email:   Phone:
          
1)

Of the people named above, please specify who will serve as the lead and co-lead.

 
 
2)

Please provide a short description of your entity and how your patients receive 340B drugs:

 
 
3)

Briefly describe the services your organization provides to ensure patient access to medications. What programs do you participate in that help to make medication purchases affordable for your organization and your patients?

 
 
4)

What clinical pharmacy or medication management services does your organization provide? Which staff members are designated to provide these services? How does your organization track the outcomes of such services and how are these outcomes used for quality improvement?

 
 
5)

Briefly describe two or three of the most effective business practices that your organization has instituted to maximize the financial and operational stability of the 340B program.

 
 
6)

What activities does your entity undertake to ensure your 340B program maintains integrity (e.g. policy and procedure, program oversight, self-audit, OPA database review, etc.)?

 
 
7)

Does your organization offer a pharmacy residency or are you active with a college or school of pharmacy's experiential education program?

 
 
8)

Describe the Quality Assurance/Quality Improvement Program that is currently in place at your organization (e.g. oversight of QA activities, pharmacy QA, patient safety committee, etc.). What types of technology, resources and/or infrastructure are used to ensure superior patient safety and 340B operation standards (e.g. scanning technologies, robotics, multiple ID, ADE/ADR identification, reporting and avoidance, etc.)?

 
 
9)

Describe any past collaborations or support activities with other 340B entities:

 
 
10)

What areas of growth do you see for your program over the next 3 years?

 
 
11)

Please describe your organization's activity in state or national safety net associations:

 
 

Person Completing Application:

 

Email: