HRSA 340B Peer-to-Peer Leading Practice Site Application

Please note: All 340B covered entities are eligible to apply. APhA recommends reviewing the Peer-to-Peer Program page on the Office of Pharmacy Affairs website prior to applying to be a Leading Practice Site. Please visit the Peer-to-Peer Program page at www.hrsa.gov/opa/peertopeer. 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 Peer-to-Peer application once complete. Once you hit submit, you will not have the ability to make changes. You will receive an email confirming receipt of your application.

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 1:

Organization Type 2:

Organization Type 3:

Primary Contact

Name:

Title/Position:

Email: Phone:

Secondary Contact

Name:

Title/Position:

Email: Phone:

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

Name:

Title/Position:

Email: Phone:

Select the option(s) that best describe your organization’s 340B operations environment

In-house Outpatient Pharmacy (entity owned and operated)In-house Outpatient Pharmacy (management company operated)In-house Pharmacy (Physician Administration as part of outpatient visit)Contract PharmacyNumber of Contract PharmaciesTelepharmacy ProgramMixed Use Pharmacy (serves inpatient and outpatient settings)Other

Is your organization currently enrolled in the Prime Vendor Program (PVP)? YesNoNot Sure

Does your organization provide 340B drugs to Medicaid patients? YesNoNot Sure

Does your organization employ a sliding fee scale? YesNoNot Sure

Does your organization serve both 340B eligible and non 340B eligible patients? YesNoNot Sure

Do any providers at your clinic/hospital also provide care outside your organization (i.e. from private practice settings)? YesNoNot Sure

Select the type of inventory system that your entity employs: YesNoNot Sure

Has your entity had a HRSA OPA 340B Audit? YesNoNot Sure

Hospitals Only

Is your hospital subject to the GPO prohibition? YesNoNot Sure

Is your hospital subject to the Orphan Drug Exclusion? YesNoNot Sure

How did you hear about the Peer-to-Peer Program/Application?

Details:

1) What makes your organization a Leading Practice Site with regard to accurate 340B database information?

2) What makes your organization a Leading Practice Site with regard to diversion prevention practices?

3) What makes your organization a Leading Practice Site with regard to duplicate discount prevention practices?

4) Is there anything else about your entity’s 340B program you would like to share?

Person Completing Application:

Email: