Contract Pharmacy Details

OPTUM FRONTIER THERAPIES II, LLC
DSH140046 SSM HEALTH GOOD SAMARITAN HOSPITAL

Covered Entity Details

Entity Name

SSM HEALTH GOOD SAMARITAN HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140046

Entity Address

1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864

Medicare Provider Number

140046

Participating Start Date

7/1/2023

Last Recertification Date

8/15/2024

Entity Termination Date

7/1/2025

Pharmacy Details

Pharmacy Name

OPTUM FRONTIER THERAPIES II, LLC

Pharmacy Address

6425 SANTA MARGARITA ST UNIT 110
LAS VEGAS, NV 89118-1913

Pharmacy Comments

Contract Details

Approval Date

7/12/2024

Contract Begin Date

10/1/2024

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2025
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Eileen Lamm, Regional Vice President-Finance
(314) 994-6219

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

7/12/2024

340B Drug Pricing Program Database