IQVIA

WhitePaper

DoPatientsReceive340B

DrugDiscountsattheContractPharmacyCounter?

RORYMARTIN,PHD,Sr.Principal,IQVIAMarketAccessTechnology&Solutions

WILLIAMSARRAILLE,JD,ProfessorofPractice,UniversityofMarylandFrancisKingCareySchoolofLawKEPLERILLICH,PHD,Consultant,IQVIAMarketAccessTechnology&Solutions

Tableofcontents

Abstract1

Introduction2

340Bdrugdiscountcards4

Methods4

Data4

Identificationof340Bdiscountsharingmechanisms4

Percentageofclaimsusinga340Bcard5

Limitations6

Findings6

Discussion8

Conclusion9

References10

Abouttheauthors12

Acknowledgements12

Abstract

Thequestionofwhetherpatientsofhospitalsand

clinicsparticipatinginthe340BDrugPricingProgram

(“340Bprogram”)receivefinancialassistancewhen

fillingprescriptionshasbecomecentralto340Bpolicydebatesandlitigation.Againstabackdropframedby

therapidincreasein340Brevenuegeneratedusing

contractpharmacies,advocatesandcriticsofthe

programoffersharplydifferentperspectivesonwhether340Bdiscountedpricesaresharedwithpatientsfillingprescriptionsatthosepharmacies.

Toaddressthatquestion,thisstudyusedanational

sampleofbranded,self-administereddrugstoexamine340Bpatientdiscountsharingatcontractpharmacies

betweenJuly2020andJune2024,completedasafollow-uptoanearlierstudyperformedbyourgroupthree

yearsago.Wefoundthat340Bdrugdiscountcards

continuedtobethedominantmechanismusedfor

sharing340Bdiscountswithpatients,whenassistancewasprovided,andthat340Bdiscountcardswereusedinapproximately0.17%ofallbrandedprescriptionsatcontractpharmacies,whether340Bornot.

InQ32020,whenthefirstmanufacturerintroduceda

contractpharmacypolicydesignedtolimittheuseof

thosepharmacies,340Bcardswereusedon3.0%of

allbranded340Bprescriptions.InQ22024,bywhich

timeapproximatelythreedozenmanufacturershad

introducedcontractpharmacypolicies,340Bcardswereusedon4.7%ofbranded340Bprescriptionsfilledat

thosepharmacies.Despite340Badvocates’assertionstothecontrary,thesedatadonotsupportthenotionthatmanufacturercontractpharmacypoliciesreducedpatientassistanceusing340Bdiscountcards.

Although340Bcardusagewasnotadverselyaffectedbymanufacturercontractpharmacypolicies,patient

assistanceusing340Bcards,bothbeforeandafter

manufacturerpolicieswereimplemented,waswell

belowthe32%ofU.S.adultswhowereuninsuredor

under-insuredatthetimeofthestudy.Disproportionatesharehospitals—whichreceivethevastmajorityof

allrevenuegeneratedbythe340Bprogram—weresubstantiallylesslikelythanhealthcentergranteestoprovidefinancialassistancetotheirpatients.

|1

Introduction

The340BDrugPricingProgram(“340Bprogram”)isa

federalprograminwhichmanufacturersprovideheavilydiscounteddrugstocertainspecifiedprovidersthataresupposedtodeliver“directcare”totheuninsuredand

theunder-insured.1Theprogramhasevolvedinways

thathavesparkedcontroversyregardingitsfinancial

impactanddistributionof340Bdrugdiscountrevenue.Acentralquestioninthepolicydebatesandlitigation

engulfingtheprogramisthecharge,madeby340B

critics,thattheevidenceof340Bpatientsreceiving

financialassistanceatthepharmacycounterispoor,

whiledefendersoftheprogramcontendthatmany340Bhospitalsandclinicsroutinelyprovidethatassistance.

Thedebatehasbeenparticularlypointedinthelitigationovermanufacturereffortstoimplementcontract

pharmacypolicies2,3,4,5andwasalsoafocusofdiscussionintheU.S.SenateHELPCommitteeMajorityStaff’s

recentlyreleasedreportonthe340Bprogram.6

Whenitwasfirstintroducedin1992,theprogram

wassmall,thenumberofallowabletypesofcovered

entitywaslimited,andtheprogramdidnotinvolveanycontractpharmacies—drugshadtobedispensedtopatientsthroughin-housepharmacieslocatedat340Bhospitalsorclinics.Aftertheprogramwascreated,theHealthResourcesandServicesAdministration(HRSA),theagencyresponsibleforoversightoftheprogram,assistedcoveredentitiesindevelopingacontracting

modelwithseparatepharmaciesdesignedtoleverage340Bpricingfordrugsthatthecoveredentitiesdonotdispenseoradminister.HRSAlaterexplainedthatthisconceptofacontractpharmacywasdevelopedbytheagencyandcoveredentities“asearlyas1993”,following“programimplementation”.7

Inacontractpharmacyarrangement,the340Bhospitalorclinicclaims340Bpricingforadrugdispensedor

administeredtoapersonatapharmacythatisnot

ownedoroperatedbythecoveredentity.Thepharmacyonlyhasacontractwiththecoveredentitytoprovide

drugstocustomersdeemedtobetheentity’spatients.Manycontractpharmacytransactionsinvolveeither

retailorspecialtymailpharmaciesaffiliatedwiththelargestcommercialpayers,theirpharmacybenefitmanagers,ortheirlarge,affiliated,nationalfor-profitretailpharmacychains.

Thescopeofcontractpharmacytransactionshas

evolvedovertime.WhenHRSAfirstpermittedcontractpharmaciesin1995,itsoughtonlytopermitasingle

contractpharmacyforeach340Bhospitalorclinic.8

However,in2010,HRSAissuedfurtherguidancethat

purportedtoallow340Bhospitalsandclinicstouseanunlimitednumberofcontractpharmacies,significantlyexpandingtheabilityofcontractpharmaciestoleverage340Bpricing.9BetweenApril2010andApril2020,the

numberofcontractpharmaciesgrew,asaresult,bymorethan4,000%.10

2|DoPatientsReceive340BDrugDiscountsattheContractPharmacyCounter?

|3

Asthe340Bprogramevolvedandexpandedandthe

numberofcontractpharmacyarrangementsincreaseddramatically,340Bpurchasessoared.Althoughthere

arefewpublishedestimatesof340Bpurchasesin

theprogram’searlyyears,becauseHRSAmadeno

informationavailabletothepublicontheprogram’ssize,1997purchaseswereestimatedtobebetween$1.1B

and$1.4Bat340Bdiscountprices,11orbetween$2.2Band$2.8Bin2024dollars.In2024,bycontrast,340Bpurchaseswereapproximately$67.9Batdiscountedprices,12meaningthatbetween1997and2024,the

programgrewbetween2,451%and3,115%.

Thisrapidincreasehasledtodebateoveritsunderlyingcausesandpolicyimplications,withprogramadvocatescontendingitsgrowthisduetomanufacturerprice

increases13,14andprogramcriticsclaimingitsgrowthisduetoincreasesinutilization,driveninlargepartby

340Brevenuemaximizationstrategies.Thesestrategiesincludeaheavyrelianceoncontractpharmacies.

Recently,severalstudiesconcludedthatutilizationandnotpriceisthepredominantdriverof340Bgrowth.15,16

Inaddition,theprogram’sexpansionhascreated

revenueopportunitiesforvariousfor-profit

stakeholders.Theyinclude(1)nationalpharmacychainsthatactascontractpharmaciesandchargeupto14%

ofthetotalreimbursementamountofthedrug,6(2)

thirdpartyadministrators,whichchargeupto20%of

thetotalreimbursementamountofthedrugtomanageclaimsand340Beligibility,6(3)wholesalers,which

generate340Brevenuebytimingdifferencesbetween

whentheybuyandselldrugs,17and(4)pharmacybenefitmanagers(PBMs)whichsharein340Brevenuethroughthespecialtypharmaciestheyown.18Significantly,astateagencyrecentlyreportedthatpaymentstocontract

pharmaciesandthird-partyadministratorsrepresented16%ofgross340Brevenueinthatstate,19which,if

appliedtotheprogram-widespreadbetween340Bsalesatlistpriceand340Bdiscountedprices($79.9Bin2024),12wouldequatetoapproximately$12.8B.

Despite340B’sintendedpurposeandthedramatic

growthoftheprogram,thereislimitedevidencethe

programdirectlybenefitsthevulnerablepopulationitwasdesignedtosupport.Forexample,despitetheprogram’srapidgrowth,charitycareratiosfor340Bhospitalsfell

bymorethan10%,from2.5%in2018to2.2%in2022.20Furthermore,totalcommunitybenefitspendingdoesnotchangeafterDisproportionateShareHospitals(DSH)—whichreceivethelion’sshareoftheprogram’sbenefits—beginparticipatingintheprogram.21

Thosestudies,however,didnotfocusonwhether340Bpharmacybenefitpatientsreceivefinancialassistanceatthecontractpharmacycounter,withadvocates

arguingthatthepatientswhoseutilizationisgenerating340Bprofitsarebenefitingfrom340Bpricesandcriticsdenyingthatisthecase.

Ourpriorstudy18providedthefirstsystematicanalysisofpatientdiscountsharingatcontractpharmacies.Using

anationalsampleofprescribersandpatientsfilling

prescriptionsfromJuly2020toJune2021,ourstudy

revealedtwoinsights:(1)340Bdiscountcards(describedbelow)weretheonlyidentifiedmechanismforpatient

discountsharing,and(2)340Bdiscountsweresharedwithpatientsinonly1.4%ofeligibleprescriptionsatcontractpharmacies.Inthoserareinstanceswherepatientswereassistedatthepharmacycounter,however,theaveragediscountforbrandeddrugswassubstantial:92.9%.

Againstthebackdropoftheprogram’srapidexpansion,theincreasingamountof340Brevenuebeingreceivedbyfor-profitstakeholders,andthegrowinguseof

contractpharmaciesasaprofitmaximizationstrategy,manufacturersbeganimplementingpoliciesattemptingtorestrictcontractpharmacyuseinlate2020.

Manufacturersexpressedconcerns,inparticular,abouttheriskthatcontractpharmacytransactionsprecipitateddiversionandduplicatediscountissues.

Litigationchallengingthecontractpharmacypolicies

subsequentlyfollowed,withthefirstsetofcases

addressingHRSAthreatsofenforcementactiondirected

4|DoPatientsReceive340BDrugDiscountsattheContractPharmacyCounter?

againstthemanufacturersandthesecondinvolving

manufacturerchallengestostatelawsmandatingsalestocontractpharmaciesatthe340Bprice.Bothsetsoflitigationinvolvedadvocatesofthe340Bprogramanditscriticsofferingstarklydifferentviewsofthedegreetowhich340Bpatientsbenefitfrom340Bpricingatthepharmacycounter,with340Badvocatescontending

thatmanufacturercontractpharmacypolicieswere

responsibleforreducingassistancetoneedypatientsatthepharmacycounter.

Thisstudyexaminesthatquestion.Specifically,we

assesswhethertheuseof340Bdiscountcardshas

persisted,whethernewmechanismsforsharing340Bdiscountswithpatientshaveemerged,whetherthereisevidenceofincreaseddirectpatientbenefitatthe

contractpharmacy,andhowtheuseof340Bdiscountcardscomparestothelevelofneedexperiencedbytheuninsuredandtheunderinsured.

340Bdrugdiscountcards

Inourpriorstudy,wefoundthat340Bdrugdiscount

cardsaretheprimarymechanismthat340Bhospitals

andclinicsusetopassonsavingsdirectlytotheir

patientsatcontractpharmacies.Thesecardscanbe

customizedintheirformularyandwithrespecttothe

amountofthe340Bdiscountbeingshared(sometimestermedtheslide).Because340Bcardsinvolvefeespaidtothecorrespondingthird-partyadministrator,coveredentitiesprefertousethematcontractpharmacies,butnotatentity-ownedpharmacies,sinceatthelatter,the340Bdiscountcanbesharedwithapatientwithouta

third-partyfeebyusingothermeans.ThesealternativemeansincludeusingalocalcashBIN/PCN/GROUP.18

Methods

Data

Prescriptionsweresourcedfromanationalsampleof

pharmacyclaimscalledLongitudinalAccessandAdjudicationDataset(LAAD)offeredbyIQVIA,usingasubsampleof

claimsthatcapturescoordinationofbenefitsdataand

whichallowedustoestimatethecostoffillingprescriptions.Thesampleincludedalltypesofdrugstypicallydispensedthroughcontractpharmacies,meaningself-administered

drugsincludingspecialtyandtraditionaldrugs,andboth

smallmoleculeproductsandbiologics.Wefocusedon

brandeddrugs,sincegenericproductsdispensedatcontractpharmaciesareoftennotclaimedas340Bbecausethe

potentialrevenuegeneratedisnotdeemedsufficienttooffsetthecostofdataacquisitionfees.23

Purchasingdatausedtoestimatethe340Bdiscountprice

ofdrugswassourcedfromIQVIAsdrugdistributiondata

(DDD)subnationalsalesdatabase.Thisisanationalsampleofmanufacturer-directandwholesalersalesto,amongothercustomers,hospitals,clinics,andretailandmailpharmacies.

Identificationof340Bdiscountsharingmechanisms

Toassesswhetherandhow340Bdiscountsareshared

withpatientsatcontractpharmacies,wefirstsought

toidentifythemechanismsusedforpassingonthese

savings,wheneverhospitalsandclinicschoosetodoso.

Weconducteddiscussionswithindustryexperts,includingthird-partyadministratorsandconsultantsonpharmacyoperationsfamiliarwiththeprogram.Throughthis

processweidentifiedonlyonemainmechanismusedwithcontractpharmacytransactions340Bdrugdiscount

cards.Wedidnotfindevidenceofanyothersignificant

orsystematicapproachesusedbyhospitalsorclinicsto

ensuretheirpatientsbenefitdirectlyfrom340Bdiscountsincontractpharmacysettings.Somesourcesdiscussed,forinstance,thatsomecoveredentitieshavebackend

meanstoprovideassistancetopharmaceuticalpatientsinconnectionwithcontractpharmacytransactions,buttheyconsistentlyacknowledgedthattheuseofsuchalternativemechanismsarenotsignificantcomparedtotheuseof

340Bdiscountcards.

|5

Weusedathree-stepprocesstoidentifyandverify340Bdiscountcards.First,wedidprimaryresearchtoidentify340Bcards.Specifically,weidentifiedthenamesofthird-partyadministratorsthatoffer340BdiscountcardsandlookedforthesenamesintheBIN/PCN/GROUPnumbersofpharmacyclaims.Here,theBIN(BankIdentification

Number),PCN(ProcessorControlNumber),andGroupnumbersareidentifiersusedtoroutepharmacyclaimstospecificpayers.Wecollected340Bdiscountcard

BIN/PCN/GROUPnumberspublishedonline.WealsoexaminedLAADpharmacyclaimstocapturevendorsthatself-identifyasproviding340Bcardsbytheuseof“340B”inBIN/PCN/GROUPnumbers.

Second,weaddedBIN/PCN/GROUPnumbersfor340Bcardsthatwehadidentifiedandverifiedwithcard

vendorsinouroriginalstudy.18

Finally,westudiedhowthe340Bcardsidentifiedin

stepsoneandtwobehavedtoconfirmtheirpharmacyreimbursementwasnearthe340Bdiscountprice,whichwasestimatedusingourDDDsample;thattheywere

filledatcontractpharmacies;andthattheyinvolved

amixofproducttypes.ThisallowedustoexcludeBIN/PCN/GROUPnumbersthatarenot340Bcards,includingindependentcharitypatientassistanceprograms,

manufacturercoupons,andhealthplans.

Percentageofclaimsusinga340Bcard

Inouroriginalstudyofpatientdiscountsharing,18whichspannedthe12monthsfromJuly2020toJune2021,weestimatedthepercentageofbrandedpharmacyclaimsusinga340Bcardasthenumberof340Bcardclaims

dividedbythetotalnumberof340B-eligibleclaims—

thesetofpharmacyclaimsthatwereeligiblefor340B

pricingfordrugs.From2020to2024,340Bsalesatlistpricegrewby85.3%,12evenasatleast37manufacturersimplementedcontractpharmacyintegritypoliciesthatattemptedtolimitthenumberofcontractpharmacies

thatcanbeusedbya340Bhospitalorclinic.Thespecificcontractpharmaciesusedbyeachhospitalorclinicafterapplyingtheserestrictionsarenotpubliclyavailable,andpolicyrulesvarybymanufacturer,byproduct,andby

entitytype.Becauseofthis,itwasinfeasibletore-useanapproachbasedon340B-eligibleclaims.

Instead,inthisstudy,weestimatedthepercentageofpharmacyclaimsusinga340Bcardbyusingthefollowingequation,inwhichthedenominatorisbasedon340Bdrugusageratherthan340Beligibility:

%340Bcardsamong30-daynormalized340Bprescriptions

=(%prescriptionsusing340Bcards)/(%prescriptionsfilledwith340Bdrugs)

Theestimatewasbasedonprescriptionsforbrandeddrugsatretailandmailpharmacies.Forthenumerator,weestimatedthat,onaverage,0.17%ofbrandedprescriptionsfilledatretailandmailpharmaciesuseda340Bcardduringthestudy.Prescriptionswerenormalizedtotheir30-dayequivalents.

Weuseddrugpurchasingdatatoestimatethedenominatorasfollows:

%of30-daynormalizedprescriptionsfilledwith340Bdrugs

(totalunitvol.for340Bdrugs)/(meanunitvol.for30daysoftherapy)

=

(totalunitvol.foralldrugs)/(meanunitvol.per30daysoftherapy)

Here,unitvolumewasbasedonDDDpurchasingdataandtheequationwassummedoverproducts.

Toestimatethetypeofcoveredentityatwhicheach

prescriptionwaswritten,weusedpreviouslyreportedmethodology.18Forcasesinwhichtheprescribing

providerworkedatmultipleentities,weselectedtheonewiththehighestlikelihood,andprescriptionswereweightedbytheir340Blikelihoodfortheassociated

coveredentitytype.Theanalysiswasperformedforprescriptionsassociatedwithdisproportionatesharehospitals(DSH),criticalaccesshospitals(CAH),rural

referralcenters(RRC),solecommunityhospitals(SCH),healthcenters(CH),children’shospitals(PED),andallotherentitytypes(“other”).

6|DoPatientsReceive340BDrugDiscountsattheContractPharmacyCounter?

Limitations

Ahandfuloflimitationsapplytothisstudy.Forexample,

althoughweusedbesteffortstodeterminethatthere

arenosystematicmechanismsotherthan340Bcardsto

share340Bdiscountswithpatientsatcontractpharmacies,atwhichnostakeholderintervieweeidentifiedanyother

mechanismthathadasignificantimpactonpatientassistance,wecannotknowthiswithcertainty.

Thealgorithmicapproachweusedtoidentifypotential340Bcardsmayhaveomittedsomeclaimsthatused

340Bcardsorincludedclaimsthatdidnotusea340B

card.Becausenopublishedlistsof340Bdiscountcardsareavailable,nootherapproachwasfeasible,althoughweincludedallcardsthatanystakeholderinterviewee

identified,aswellasothersthatweidentifiedseparately.

Theriskofincludingnon-340Bcardclaimsmaybe

higherforpotential340Bcardsusedasasecondarypayer,becauseothercostreductionmechanismssuchasmanufacturercouponsaremostfrequentlyusedassecondarypayers.

AlthoughtheLAADsampleweusedforpharmacyclaimshashighcapture,itscapturerateisnot100%.Inaddition,itwasnecessaryforustouseasubsetofthissamplethathascoordinationofbenefitsinformation.Evenso,webelieve

thissampleisrepresentativeofthemarketasawhole.

Drugpurchasingdatawasusedtohelpestimatethe

prevalenceof340Bcardusage.Nootherapproachwasfeasiblebecausetherearenoidentifiersonpharmacyclaimsthatidentifytheuseof340Bdrugsotherthan

340Bmodifiers,andonly4%ofbranded,340B-eligiblepharmacyclaimscontainsuchmodifiers.24Thefailureofpayers,includingtheMedicareprogram,tomandatetheuseof340Bmodifiersisasignificantcontributortothelackoftransparencyinthe340Bprogram.

Findings

From2020Q3to2024Q2,thepercentageofclaimsfilledwith340Bcardsasapercentageofallprescriptionswasverylow,approximately0.17%.Thepercentageof340Bbrandedprescriptionsatcontractpharmaciesthatuseda340Bcardasapercentageoftotalestimated304B

prescriptions,thesubsetofutilizationmostlikelyto

reflectdrugcarduse,wasstilllow,rangingfrom3.0%to4.7%withinthefouryearstudyperiod(Figure1).InQ3

2020,whenonlyonemanufacturerhadimplemented

acontractpharmacypolicy,thepercentageof340B

brandedprescriptionsatcontractpharmaciesinvolving340Bcardswas3.0%.Fromthattimeuntilthesecond

quarterof2024,duringwhichapproximatelythreedozenmanufacturersimplementedcontractpharmacypolicies,thepercentageof340Bbrandedprescriptionsatcontractpharmaciestrendedupwards,reachingapeakinQ12024andendingat4.7%inQ22024.

Figure1.Percentageofbranded,340Bclaimsatretailandmailpharmaciesthatuseda340Bdiscountcard

6%

%Claims

5%

4%

3%

2%

1%

0%

2021202220232024

Year

|7

Whena340Bcardwasused,thepricepaidbythepatientforbrandeddrugswasapproximately87.5%lowerthanthecashpriceforthosedrugs.Foreachbrandedproduct,weestimatedthepricepaidbypatientswhodidnothaveinsurance(“cashprice”)andthepricepaidbypatients

using340Bcards.Theratioofthetwowascalculated

foreachproduct,andresultswerecombinedusingtheutilizationof340Bcardclaimstoestimateanaverage

priceratioof12.5%.Thisrepresentsanaveragediscountof87.5%for340Bcards,whentheywereused.

Wewouldhavelikedtobreakoutthefrequencyof340Bdiscountcardusagebycoveredentitytype,butthiswasnotpossibleduetothelackofamandaterequiringtheuseof340Bmodifiersinclaimsdata.Instead,foreach

entitytype,wefirstestimateditspercentageshareof

brandedprescriptionsfilledatcontractpharmaciesusing340Bdiscountcards.Wethencomparedthatnumberto

theentity’sexpectedshareof340Bcardprescriptions

basedonitsshareofallbranded340Bprescriptionsfilledatcontractpharmacies,withorwithouta340Bcard.

ThosefindingsaresummarizedinFigure2.

AlthoughDisproportionateShareHospitals(DSH)

generated74.7%of340Bcontractpharmacy

prescriptions,theyaccountedforonly42.8%of340B

discountcards.Accordingly,theirusageof340Bcards

wasbelowthelevelexpectedbasedonthenumberof

branded,340Bprescriptionstheygenerateatcontract

pharmacies.Similarly,ruralreferralcentersgenerated

8.1%ofprescriptions,buttheygeneratedonly2.3%of

340Bcards,or72%lessthanexpected.Incontrast,criticalaccesshospitals,solecommunityhospitals,andhealth

centerscontributedmorebranded,340Bcardusethantheirshareofprescriptions.

Figure2.Shareofbranded,340Bprescriptionsfilledatcontractpharmaciesusing340Bdiscountcards(upperbarofeachpair)versustheshareofbranded,340Bprescriptionsfilledatcontractpharmacies(lowerbarofeachpair)

42.8%

DSHHospitals

74.7%

2.3%

RuralReferralCenters

8.1%

16.6%

CriticalAccessHospitals

SoleCommunityHospitals

7.0%

13.5%

3.2%

22.7%

HRSA-FundedHealthCenters

2.8%

Children'sHospitals

0.0%

2.0%

Other

2.1%

2.2%

0%20%40%60%80%

%oftotal

340Bcards340Bprescriptions

8|DoPatientsReceive340BDrugDiscountsattheContractPharmacyCounter?

Discussion

Thisstudyexploresfourcriticalaspectsofwhetherand

how340Bhospitalsandclinicsprovidefinancialassistancetotheirpatientsatcontractpharmacies.Theyare(1)

whether340Bcardusagehasremainedthepredominantmechanismusedby340Bhospitalsandclinicstoprovidefinancialassistancetopatientsatcontractpharmacies,(2)trendsin340Bfinancialassistanceusing340Bcardsbeforeandaftertheimplementationofmanufacturer

contractpharmacypolicies,(3)theadequacyoffinancialassistancevia340Bcardsascomparedtotheextentoftheunderlyingneed,and(4)differencesin340Bcard

usagebycoveredentitytype.

Ourfindingsindicatethatsinceouroriginalstudy,18340Bdrugdiscountcardshavecontinuedtobeusedbysome340Bhospitalsandclinicstosupportarelativelysmall

proportionoftheirpatientsatcontractpharmacies.Allofthestakeholdersthatweinterviewedconfirmedthat340Bdrugcardsweretheprimarymechanismtodeliverfinancialassistanceto340Beligibledrugpatientsat

contractpharmaciesandthatnoothermechanismwasusedtoasubstantialdegree.

340Badvocatescontendthatmanufacturercontract

pharmacypolicieshavereducedfinancialassistanceto

340Bpatientsatcontractpharmacies.However,wecouldfindnoevidencetosupportthisassertion.Infact,the

usageof340Bdiscountcardsforbrandeddrugsincreasedfrom3.0%inQ32020atthestartofourstudyperiod,

whenonlyasinglemanufacturerhadimplementedsuchapolicy,to4.7%inQ2,2024attheendofourstudyperiod,bywhichtimeapproximatelythreedozenmanufacturershadinitiatedpolicies.

Althoughsomeincreasein340Bcarduseoccurredafter

implementationofdrugmanufacturerpolicies,thelow

rateoffinancialassistanceprovidedby340Bhospitals

andclinicstotheirpatientsatcontractpharmacies,

bothbeforeandafterthosep