MOST FAVORED NATION (MFN) RATE
The Georgia Department of Community Health requires that pharmacy providers report their
Most Favored Nation (MFN) rates annually and whenever they have a rate change. This request
is for the 2015 - 2016 renewal cycle and will ensure proper provider reimbursement for
pharmacy services.
Below is the MFN Rate Reporting policy as stated in Part II Policies and Procedures for
Pharmacy Services.
1001 Most Favored Nation (MFN) Rate Reporting
Most Favored Nation (MFN) is the lower of the lowest price reimbursed to the pharmacy by other
third party payers or the lowest price routinely offered to any segment of the general public as
determined by DCH. When determining an MFN rate, pharmacy providers should not include Care
Management Organization (CMO) contracted rates, State Health Benefit Plan (SHBP) rates, or
Medicare Prescription Drug Plan (PDP) rates. At a frequency of at least annually (between April 1st
and June 30th), enrolled pharmacy providers must report their MFN rate in writing to the Medicaid
Pharmacy Services Unit. Failure to report current MFN rates may result in recoupment of any
overpaid fees and/or termination.
Attached are two MFN Reporting forms. One form should be completed by “for-profit”
providers, and the other form should be completed by “not-for-profit” providers. Please complete
and return the applicable MFN Reporting Form by June 30, 2015.
You may fax your form to Pharmacy Services at 1-877-567-8001, or mail it to the following
address:
Department of Community Health
Pharmacy Services
2 Peachtree Street, N.W. 37th Floor
Atlanta, Georgia 30303
The MFN Rate Reporting Form may also be downloaded from www.mmis.georgia.gov →
Provider Information → Forms → Reporting Form for MFN Rates.
If you have questions or concerns, please do not hesitate to contact the Department at (404) 6564044.
We thank you for your continued service and participation in the Georgia Medicaid & PeachCare
for Kids Programs.
MFN Reporting Form (For-Profit Pharmacy)
Please complete the form below and return it to Pharmacy Services via fax at the
following number: 1-877-567-8001.
Thank You!
Pharmacy Name: ________________________________________________________
Address: _______________________________________________________________
City: ___________________________ State: ____________Zip Code: _____________
Phone: _______________Fax: _______________E-mail: ______________________
Name of Contact: ________________________________________________________
Please Print
NCPDP: _____________ Medicaid No.: ______________NPI: _________________
Most Favored Nation reimbursement rate:
Please note: CMO contracted rates, SHBP rates, and Medicare PDP rates should not be
included when determining your MFN rate.
AWP - %
+
Dispensing Fee
Brand Discount is _________% Brand Dispensing Fee is $__________
Generic Discount is________% Generic Dispensing Fee is $__________
MAC + $_________________
_____________________________________________
Signature
_______________________
Date
It is important to notify the Medicaid office when there is a change in your MFN rate. See
section 1001 in Part II of the Pharmacy Policies and Procedures Manual on the
www.mmis.georgia.gov website.
MFN Reporting Form (Non-Profit Pharmacy)
Please complete the form below and return it to Pharmacy Services via fax at the
following number: 1-877-567-8001.
Thank You!
Pharmacy Name: ___________________________________________________________________
Address:___________________________________________________________________________
City: _________________ State: ______________Zip code: ________________________________
Phone: ________________ Fax: ________________ E-mail: _______________________________
Name of Contact: ___________________________________________________________________
Please Print
NCPDP: _____________ Medicaid No.: ________________Pharmacy NPI:__________________
Most Favored Nation reimbursement rate:
1001 Non-Profit Pharmacy
Non-profit pharmacies shall bill an amount not greater than the dispensing fee plus the actual acquisition
cost of the drug. Non-profit pharmacies shall also include pharmacies purchasing under the Minnesota
Multistate Contracting Alliance for Pharmacy (MMCAP) program.
Dispensing fee: _______________________
Acquisition cost: as defined by 1001 above
___________________________________________________
Signature
____________________________
Date
It is important to notify the Medicaid office when there is a change in your MFN rate. See
section 1001 in Part II of the Pharmacy Policies and Procedures Manual on the
www.mmis.georgia.gov website.