The 340B Rebate Model Pilot is about to go live, and while everyone is writing breakdowns of the risks, the cash-flow hit, and how Beacon will handle claims, hardly anyone is giving Covered Entities something actually tactical and usable inside the clinic on Day 1. We do it differently here at Alchemy by providing our partners tactical advice they can put into play right away.
So here’s a resource made specifically for prescribers, pharmacists, clinical directors, and anyone trying to avoid operational chaos come January: A therapeutic substitution cheatsheet for all 10 drugs in the rebate pilot with dosing, class-equivalents, and 340B-specific notes.
This isn't a strategy. This is what your frontline teams will need to know when a prescriber asks:
“Wait… this drug is in the pilot? What else can I safely use that’s not in the pilot?”
Below is the quick-view PDF version that you can download and distribute to your clinical teams.
Why a “formulary swap” strategy deserves serious attention
One strategic lever many CEs are overlooking: when faced with a drug that’s been selected for the rebate-model pilot, consider proactively swapping it out for a therapeutically equivalent agent not subject to the pilot. In short, avoid entering the rebate trap when you can safely substitute with a non-pilot drug that meets the same clinical need.
Benefits of this approach:
- Maintains your traditional 340B upfront-discount model (for non-pilot drugs).
- Reduces exposure to administrative/financial risk from rebate delays or claim issues.
- Lets you preserve margins, cash flow, and operational simplicity.
- Gives prescribers a clear, actionable “cheatsheet” for alternatives making the transition smoother for clinicians and patients.
Key Considerations Before You Pull the Switch
- Clinical appropriateness: Ensure the substitute drug truly matches the indication, patient profile (renal/hepatic function, comorbidities), dosing, monitoring, safety profile.
- Formulary/contracting alignment: Are the alternative agents on your formulary? Are they covered by payers? Will substitution force a change in pharmacy workflow or prior-authorization burden? Will the substituted drug yield similar 340B net proceeds?
- 340B eligibility and contract-pharmacy implications: For each alternative, confirm it is safe from any manufacturer/contract-pharmacy restrictions and remains eligible for 340B acquisition.
- Budgeting and cash-flow modeling: If you stay with the pilot drug, model the impact of paying WAC today and waiting for rebate tomorrow. If you switch, model price/contract differences, reimbursement differences, and potential clinical workflow costs.
- Provider engagement: Prescribers must know the substitution strategy and the “why” behind it. Their clinical comfort and patient communication matter.
The Targeted Drugs & Substitution Cheatsheet
Below is a list of the ten (10) high-cost drugs selected for the pilot and then the clinic-friendly substitution chart below. Use it as your go-to resource for prescribers, formulary teams, and clinic workflows.
The 340B rebate model pilot covers:
- Eliquis (apixaban)
- Enbrel (etanercept)
- Farxiga (dapagliflozin)
- Imbruvica (ibrutinib)
- Januvia (sitagliptin)
- Jardiance (empagliflozin)
- Novolog (insulin aspart)
- Fiasp (faster aspart)
- Stelara (ustekinumab)
- Xarelto (rivaroxaban)
These represent early “Phase 1” of the pilot. While targeted, they cross major therapeutic categories (anticoagulation, biologics, diabetes/metabolic, oncology). Your exposure is likely if your clinic uses any of these.
1. Eliquis (apixaban) – Oral Factor Xa inhibitor
Alternatives:
- Savaysa (edoxaban) – Factor Xa inhibitor
- Arixtra (fondaparinux) – injectable Xa inhibitor
- Warfarin – Vitamin K antagonist
- Pradaxa (dabigatran) – direct thrombin inhibitor
2. Enbrel (etanercept) – TNF inhibitor (rheumatology/dermatology)
Alternatives:
- Humira (adalimumab) + biosimilars
- Cimzia (certolizumab)
- Simponi (golimumab)
- Remicade (infliximab) + biosimilars
- Taltz (ixekizumab) – IL-17 inhibitor (indication-dependent)
- Cosentyx (secukinumab) – IL-17 inhibitor
3. Farxiga (dapagliflozin) – SGLT2 inhibitor (diabetes/HF/CKD)
Alternatives:
- Invokana (canagliflozin)
- Steglatro (ertugliflozin)
4. Imbruvica (ibrutinib) – BTK inhibitor
Alternatives:
- Calquence (acalabrutinib) – preferred in many guidelines
- Brukinsa (zanubrutinib) – often better tolerated
- Pirtobrutinib (Jaypirca) – non-covalent BTK inhibitor, for resistant disease
5. Januvia (sitagliptin) – DPP-4 inhibitor
Alternatives:
- Onglyza (saxagliptin)
- Tradjenta (linagliptin)
- Nesina (alogliptin)
(Or switch classes entirely → GLP-1 agonists, SGLT2 inhibitors.)
6. Jardiance (empagliflozin) – SGLT2 inhibitor
Alternatives (same class):
- Invokana (canagliflozin)
- Steglatro (ertugliflozin)
(And vice-versa with Farxiga.)
7. Novolog (insulin aspart)
Alternatives: Rapid-acting analogs (closest equivalents)
- Humalog (insulin lispro) + biosimilars
- Apidra (insulin glulisine)
Regular insulins:
- Humulin R
- Novolin R
8. Fiasp (fast-acting insulin aspart)
Alternatives:
- Humalog (insulin lispro)
- Lyumjev (ultra-rapid lispro)
- Apidra (insulin glulisine)
9. Stelara (ustekinumab) – IL-12/23 inhibitor
Psoriasis/PsA Alternatives:
- Cosentyx (secukinumab) – IL-17
- Taltz (ixekizumab) – IL-17
- Humira/Adalimumab biosimilars
- Skyrizi (risankizumab) – IL-23
- Ilumya (tildrakizumab) – IL-23
- Tremfya (guselkumab) – IL-23
Crohn’s Alternatives:
- Skyrizi (risankizumab) – IL-23
- Remicade (infliximab) + biosimilars
- Humira (adalimumab) + biosimilars
- Entyvio (vedolizumab) – gut-selective
10. Xarelto (rivaroxaban) – Oral Factor Xa inhibitor
Alternatives:
- Savaysa (edoxaban)
- Pradaxa (dabigatran) – DTI
- Warfarin
- Arixtra (fondaparinux) – injectable Xa inhibitor
