Georgia Rebate Program Information
This site has been established by Goold Health Systems, (GHS), for the use of Georgia Medicaid Drug Manufacturers, Pharmacy Providers, DURB members and any other interested parties.
Most Favored Nation
Georgia State Medicaid’s Most Favored Nation Policy (MFN) refers to the requirement for providers to bill DCH Medicaid at the lowest rate accepted from any other payer, whether it is a charitable donation or a senior citizen incentive. If the price charged is lower than AWP -11% + $4.63, all or part, then the same rate must be submitted to Medicaid for reimbursement. MFN submissions are submitted to the Department using the attached form, for confirmation and reimbursement methodology accordingly.
Excerpts from Georgia's provider manual in reference to
the Most Favored Nation policy
The cost of the drug will be based upon the lowest of AWP less 11%; federal upper limit (FUL), Georgia maximum allowable cost (GMAC) or the provider‘s usual and customary charges or Most Favored Nations (MFN) pricing. (See the Pharmacy Services Manual)
602.1 Determining Usual and Customary Charges
For-profit providers must submit their usual and customary charge when billing the Division for Medicaid prescriptions. The Division defines usual and customary as the lower of the lowest price reimbursed to the pharmacy by other third party payers (including HMO‘s); or, the lowest price routinely offered to any segment of the general public. For example, if a pharmacy offers discounts to Senior Citizens or children, the same discounted price must be billed to the Division. Likewise, a pharmacy that provides prescription refills at no charge must not bill the Division for a refill provided to a Medicaid member. Donations or discounts provided to a charitable organization or fees charged to or paid by federal or state funded programs are not considered usual and customary charges.
602.1a 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 rares, State Health Benefit Plan (SHBP) rates, or Medicare Prescription Drug Plan (PDP) rates. At a frequency of at least annually (between August 1st and November 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
Drug Utilization Trends
Product utilization and trend analysis is outside the scope and contractual responsibilities provided by Goold Health System (GHS) as a DCH vendor. When a labeler finds utilization trends higher or lower than expected in a quarter GHS suggest you consider the following factors: Preferred Drug List (PDL) changes, multi-source Brand availability, seasonal variability, new Brand or generic drug availability or the marketing release of an Rx drug to OTC status. The PDL can be found at: http://dch.georgia.gov/00/channel_title/0,2094,31446711_32050640,00.html
Mandatory Date
Georgia Rebate begins paying for drugs on or after the mandatory effective reported to the State by the CMS drug rebate program.
Invoice Payment Information
If you are a participant in both OBRA and Supplemental programs remit a separate check for each of these. OBRA and J-code payments can be submitted in one check as they go to the same bank deposit lockbox.
Remit payment for the OBRA & J-code Invoices to:
Division of Medical Assistance
P.O. Box 198194
Atlanta, GA 30384-8194
Make checks payable to the Division of Medical Assistance.
Remit payment for the Supplemental or State special invoices to:
Division of Medical Assistance
P.O. Box 404331
Atlanta, GA 30384-4331
Make checks payable to the Division of Medical Assistance.