CMS-10912 CMS-10912.MTF_ICR_DispensingEntityEnrollmentForm_clean

Appendix A: Drug Price Negotiation Program MTF DM Dispensing Entity and Third-Party Support Entity Enrollment Form

Under the authority in sections 11001 and 11002 of the Inflation Reduction Act of 2022 (P.L. 117-169), the Centers for Medicare & Medicaid Services (CMS) is implementing the Medicare Drug Price Negotiation Program (“the Negotiation Program”), codified in sections 1191 through 1198 of the Social Security Act (“the Act”). The Act establishes the Negotiation Program to negotiate a maximum fair price (“MFP”), defined at section 1191(c)(3) of the Act, for certain high expenditure, single source drugs covered under Medicare Part B and Part D (“selected drugs”). In accordance with section 1193(a) of the Act, any Primary Manufacturer of a selected drug that continues to participate in the Negotiation Program and reaches agreement upon an MFP for the selected drug must provide access to the MFP to MFP-eligible individuals, defined in section 1191(c)(2)(A) of the Act, and to pharmacies, mail order services, other dispensing entities, providers and suppliers with respect to such MFP-eligible individuals who are dispensed that selected drug during a price applicability period.

To facilitate the effectuation of the MFP, CMS will engage a Medicare Transaction Facilitator (MTF). The MTF system will be comprised of two modules: the MTF Data Module (MTF DM) and the MTF Payment Module (MTF PM). Primary Manufacturers participating in the Negotiation Program are required to participate in the MTF DM. In recent rulemaking, CMS finalized a requirement for Part D plan sponsors to include in their pharmacy agreements provisions requiring dispensing entities to be enrolled in the MTF DM..¹ Dispensing entity enrollment in the MTF DM is needed for necessary operations related to administration of the Negotiation Program and the Part D program, including creating and making available remittances or ERAs, maintaining access to the complaints and disputes submission portal, facilitating continued access to selected drugs that are covered Part D drugs, and ensuring accurate Part D claims information and payment. As discussed in section 40.4 of the Medicare Drug Price Negotiation Program: Final Guidance, Implementation of Sections 1191 – 1198 of the Social Security Act for Initial Price Applicability Year 2027 and Manufacturer Effectuation of the Maximum Fair Price (MFP) in 2026 and 2027 (“final guidance”), CMS will engage the MTF DM to facilitate the exchange of certain claim-level data elements and claim-level payment elements for selected drugs. The data exchange component of the MTF will involve both the transmission of certain claim-level data elements to the Primary Manufacturer and receipt of claim-level payment elements from the Primary Manufacturer.

This form is designed to collect the necessary information to process dispensing entity and third-party support entity enrollment in the MTF DM. Completing this form within the MTF DM enrollment module’s user interface will result in dispensing entities securing access to the MTF DM, enabling these entities to elect their preference for receiving MFP refund payments from the participating Primary Manufacturers, access reports related to their MFP-eligible claims, and access complaint and dispute functionality. This form will need to be completed only once for each dispensing entity enrolling in the MTF DM and kept up to date over time.

General information about CMS’ work related to the IRA is available at https://www.cms.gov/inflation-reduction-act-and-medicare.

The relevant statute pertaining to this ICR can be found at this link: https://www.congress.gov/117/plaws/publ169/PLAW-117publ169.pdf

The relevant guidance pertaining to this ICR can be found at this link: https://www.cms.gov/files/document/medicare-drug-price-negotiation-final-guidance-ipay-2027-and-manufacturer-effectuation-mfp-2026-2027.pdf

General Instructions

Overview

Dispensing entities submitting Medicare Part D claims from MFP-eligible individuals should complete only Part I of this form. Part I requires the completion of the following sections:

• “Dispensing Entity MTF DM User Roles” (Section 1),

• “Dispensing Entity Identification Information” (Section 2),

• “Dispensing Entity Financial Information” (Section 3),

• “Dispensing Entity MFP Refund Payment Instructions for Primary Manufacturers Not Participating in the MTF Payment Module” (Section 4)

• “Dispensing Entity Contact Information” (Section 5), and

• “Dispensing Entity Certification” (Section 6)

The dispensing entity is responsible for determining and acquiring information necessary to complete Part I, and for maintaining the completeness and accuracy of the requested information in the MTF DM as long as the dispensing entity is enrolled in the MTF DM. The dispensing entity must complete the certification (Section 6) to finalize the submission of this form.

Third-party support entities that contract with a dispensing entity to provide prescription-related, administrative, or intermediary services to a dispensing entity, such as a pharmacy services administrative organization (PSAO) or reconciliation vendor, should complete only Part II. Part II requires the completion of the following sections:

• “Third-Party Support Entity MTF DM User Roles” (Section 1),

• “Third-Party Support Entity Identification Information” (Section 2),

• “Third-Party Support Entity Financial Information (Section 3), and

• “Third-Party Support Entity Certification” (Section 5)

“Third-Party Support Entity Financial Information” (Section 4) should also be completed if a third-party support entity is designated by a dispensing entity to receive aggregated MFP refund payments from Primary Manufacturers through the MTF PM on its behalf. The third-party support entity must complete the certification (Section 5) to finalize the submission of this form.

Questions about this ICR and dispensing entity and third-party support entity enrollment in the MTF DM should be sent to [email protected]. For technical assistance related to the enrollment submission process, questions should be sent to [email protected]. 

Submission Method

• Dispensing entities, and any third-party support entities that intend to play a supporting role in dispensing entity receipt of MFP refunds, enrolling in the MTF DM should submit information related to this ICR via the MTF DM.

• Instructions for dispensing entities and third-party support entities to gain access to the MTF DM to submit information related to this ICR will be available on the Medicare Drug Price Negotiation Program website.
  
  
  

Additional Instructions

• The instructions in this section apply to all information submitted by dispensing entities and third-party support entities.

• Dispensing entities under common ownership should be enrolled by their parent organization or chain home office. The parent organization or dispensing entity “chain home office” (hereinafter “dispensing entity CHO”) is responsible for completing this form on behalf of all associated locations. If a parent organization is organized into multiple dispensing entity CHOs (e.g., regionally) with claims reimbursement directed to different bank accounts for each sub-component, each dispensing entity CHO may enroll in order to align MFP refund payment with the appropriate payment destination; however, individual locations (e.g., stores under the CHO) should not enroll independently under these circumstances. Note that each MTF DM enrollment will be associated with a single payment destination for MFP refunds.

• For purposes of this information collection request, all defined terms referenced in this ICR have their meaning set forth in the final guidance. 

• Questions about the final guidance, including questions about terms defined in the guidance and used in this ICR, should be sent to [email protected].

• Response formats are indicated within each question in this ICR. 

• Additional information regarding the Medicare Drug Price Negotiation Program can be found on CMS’ website here.

Part I: Dispensing Entity Enrollment Questionnaire

Section 1: Dispensing Entity MTF DM User Roles

Section 1 requires the entity completing Part I to assign MTF DM user roles for any individuals they wish to have user access to the MTF portal. Generally, the Authorized Signatory Official will have the most capabilities within the MTF while the Staff End User will have the least capabilities within the MTF DM. The dispensing entity should determine how many user roles are appropriate depending on the dispensing entity’s staffing resources and business practices. Additional information on assigning user roles and user management will be detailed in upcoming technical instructions.

• Authorized Signatory Official: An appointed individual of the dispensing entity with authority to legally bind that organization in agreements, represent the organization in an official capacity, and act on behalf of an organization. To be eligible, the Authorized Signatory Official must meet one or more of the following criteria: (1) serve as the Chief Executive Officer (CEO), where the individual has been duly appointed by the organization’s board or other governing body; (2) serve as the Chief Financial Officer (CFO), where the individual has been duly appointed by the organization’s board or other governing body; (3) serve in a role other than as the CEO or CFO, where the individual has authority that is equivalent to a CEO or CFO; or (4) serve in a role, where the individual has been granted directly delegated authority to legally bind the organization on behalf of one of the individuals previously noted in (1)-(3).

• Access Manager: An individual, designated by the Authorized Signatory Official of the dispensing entity authorized to act on behalf of the organization to view, modify, submit, and certify the completeness and accuracy of the information on this form and to submit complaints and disputes in the MTF DM on behalf of the organization.

• Staff End User: An individual, designated by the Access Manager of the dispensing entity authorized to perform more limited tasks, such as view and download information in the MTF DM and submit complaints and disputes in the MTF DM on behalf of the organization.

Instructions

• Review the table below and ensure each individual’s user role is accurate.

Drop-down Menu	Response Format – Full Name	Response Format – Email Address
[Drop-down Menu]	Prepopulated by MTF	Prepopulated by MTF
[Drop-down Menu]	Prepopulated by MTF	Prepopulated by MTF
[Drop-down Menu]	Prepopulated by MTF	Prepopulated by MTF
[Drop-down Menu]	Prepopulated by MTF	Prepopulated by MTF

Section 2: Dispensing Entity Identification Information

Section 2 requires identifying information about the dispensing entity, including federally issued identifying information and demographic, geographic, and relationship information for verification purposes and to enable enrollment in the MTF DM.

Instructions

• Dispensing entities are required to answer all questions. If the question is not applicable, please indicate this in the corresponding text field by entering “Not Applicable.”

• Question 1 asks for authorization to use the dispensing entity’s self-reported information to the National Council of Prescription Drug Programs (NCPDP) to optimize MTF Data Module enrollment procedures. If authorization is not given, the dispensing entity will be required to manually enter the requested information in Question 2 or upload a roster.

• Question 2 asks for identifying information for verification purposes, which, depending on your response to Question 1, may be prepopulated for you using the NCPDP dataQ Pharmacy Database.

• Question 3 provides an opportunity for dispensing entities to self-identify as anticipating material cashflow concerns at the start of the initial price applicability year due to the shift from payment by the Part D sponsor to a combination of Part D sponsor payment plus a potentially lagged MFP refund. Responses to this question are optional and will be treated as confidential and shared with Primary Manufacturers for purposes of informing Primary Manufacturer’s development of their MFP Effectuation Plan only. For example, CMS expects that certain types of dispensing entities—such as sole proprietor rural and urban pharmacies with high volume of Medicare Part D prescriptions dispensed; pharmacies who predominantly rely on prescription revenue to maintain business operations; long-term care pharmacies; 340B covered entities with in-house pharmacies; and Indian Health Service, Tribal, and Urban Indian (I/T/U) pharmacies—may have material concerns about cashflow related to the effectuation of MFP.

As stated in section 90.2.1 of the Final Guidance, CMS will make the list of the self-identified dispensing entities available to Primary Manufacturers in the MTF DM prior to Primary Manufacturers’ submission of MFP Effectuation Plans for 2026 and 2027 and will provide updates to reflect changes to the list of dispensing entities that self-identify as having material cashflow concerns. CMS views sharing this list as informational; Each Primary Manufacturer may establish its own mitigation approach, which must be described in the Primary Manufacturer’s MFP Effectuation Plan; selecting “Yes” does not guarantee the dispensing entity will gain access to any Primary Manufacturer’s mitigation process.

Section 2, Question 1. Please indicate below if you authorize the MTF to use and rely on the dispensing entity’s information as reported to NCPDP dataQ Pharmacy Database. Your response does not affect your ability to designate the dispensing entity as the direct recipient of MFP refund payments or to designate the third-party support entity listed in the database as the recipient (see Section 3, Questions 1-1A). Your response will guide how we collect your identifying information and optimize enrollment procedures in the MTF Data Module. Accordingly, please ensure that your information in NCPDP dataQ Pharmacy Database is correct and up to date prior to completing this enrollment form.

Selecting “Yes” means a copy of the most recent information from NCPDP dataQ Pharmacy Database will be displayed in Question 2 for your verification.

Selecting “No” means the required identifying information will need to be entered manually in Question 2.

Field	Response Format
Yes	☐
No	☐

Section 2, Question 1A. If “Yes” was selected in response to Section 2, Question 1, the information in the following fields may be prepopulated with identifying information from the NCPDP dataQ Pharmacy Database based upon the user management process. Please note that the NCPDP Provider ID is relevant to non-chain dispensing entities (i.e., community or independent pharmacies).

Field	Response Format
Legal Business Name OR	Prepopulated by MTF
Doing Business As (DBA) Name OR	Prepopulated by MTF
NCPDP Relationship ID (for chains when NCPDP relationship type = 01) OR	Prepopulated by MTF
NCPDP Provider ID (for non-chains)	Prepopulated by MTF

Section 2, Question 2. A complete and accurate roster of your organization’s location, including any associated dispensing entity locations, is required. Based on your response to the previous questions, the following table may be prepopulated with information from NCPDP dataQ™ Pharmacy Database for verification. Accordingly, please verify the accuracy of the prepopulated information.

If you have opted not to authorize use of the NCPDP dataQ™ Pharmacy Database, please complete the following table, adding rows as applicable, or, if preferred, please upload a roster containing the requested information. If manually entering information and mailing address and business address are the same, please indicate that in the text box or document rather than filling out the same address twice.

Legal Business Name	Doing Business As (DBA) Name	Store Location # (if applicable)	Mailing Address	Business Address	NCPDP “Provider ID”	Pharmacy National Provider Identifier (NPI)	State License Number (optional)	Federal Tax Identification Number
Text or prepopulated by MTF	Text or prepopulated by MTF	Text or prepopulated by MTF	Text or prepopulated by MTF	Text or prepopulated by MTF	Text or prepopulated by MTF	Text or prepopulated by MTF	Text or prepopulated by MTF	Text or prepopulated by MTF

OR

[DOCUMENT UPLOAD]

Section 2, Question 3. (OPTIONAL) This dispensing entity is self-identifying as a dispensing entity that anticipates material cashflow concerns for at least one location at the start of the initial price applicability year due to the shift from payment by the Part D sponsor to a combination of Part D sponsor payment plus a potentially lagged MFP refund.

Field	Response Format
Yes	☐
No	☐
I Prefer Not to Answer	☐

Section 2, Question 3A. If “Yes” was selected in response to Question 3, please list the pharmacy NPIs for which the anticipated material cashflow concerns apply, or upload a file that contains the applicable list of pharmacy NPIs. If “No” was selected in response to Question 3, please do not answer this question and skip to Section 3.

Field	Response Format
List of applicable NPIs with anticipated material cashflow concerns	Text

OR

[DOCUMENT UPLOAD]

Section 3: Dispensing Entity Financial Information

Financial information and account details are needed in connection with the MFP refund payment from the Primary Manufacturer to the dispensing entity. This information may also be necessary for establishing accurate remittance advices or ERAs.

Instructions

• Dispensing entities are required to answer all questions.

• In completing this section, please note the following:

  • The financial institution’s name must be the legal business name of that financial institution.

  • The account to which electronic transfer of funds payments is made must bear the account holder’s name and legal business name.

  • Account number should include applicable leading zeros.

• Dispensing entities are responsible for maintaining the accuracy of information in this section and reporting any changes over time. Upon any change to the information in this section, the information in this form should be updated via the MTF DM user interface. Failure to promptly update information may cause delays or interruptions in processing of MFP refunds.

• Under Section 3, Question 1E of this section, please submit a voided check or a letter on the bank’s letterhead for verification purposes. This helps to ensure the accuracy of account details and prevents errors in payment processing. Only one type of documentation is needed. When submitting the banking verification documentation, it should contain the name on the account (account holder’s name), routing number, account number, and account type. If submitting bank letterhead, the bank officer’s name and signature is also required. NOTE: Supporting bank documents must be in the organization’s legal business name only.

• Question 3 concerns tax reporting information. Nonprofit dispensing entities will not receive an IRS Form 1099.

Section 3, Question 1. Irrespective of your decision to authorize the MTF to rely on your information in the NCPDP dataQ™ Pharmacy Database, you retain the option to have MFP refund payments sent either to a third-party support entity listed in that database or to yourself.

Please confirm whether the dispensing entity is using a third-party support entity for purposes of the MTF:

Field	Response Format
Do you want to use the third-party support entity listed in NCPDP dataQ to process your MFP refund payments?	☐ Yes ☐ No

If yes, please select the entity to which MFP refunds should be sent. If no, MFP refund payments will go directly to the dispensing entity.

Field	Response Format
Name of entity to which MFP refund payments should be sent	Dropdown menu of third-party support entities in NCPDP dataQ

Section 3, Question 1A. Irrespective of your decision to authorize the MTF to rely on your information in the NCPDP dataQ™ Pharmacy Database, you retain the option to make ERAs or remittance advice available either to a third-party support entity listed in that database or to yourself.

Field	Response Format
Do you want to use the third-party support entity listed in NCPDP dataQ to receive your ERAs or remittance advice?	☐ Yes ☐ No

If yes, please select the entity to which ERAs or remittance should be made available. If no, ERAs or remittances will be made available only to the dispensing entity.

Field	Response Format
Name of entity to which ERAs or remittance advice should be made available	Dropdown menu of third-party support entities in NCPDP dataQ

Please confirm, as applicable, that the dispensing entity and the third-party support entity have mutually agreed that the third-party support entity named above is authorized to act on behalf of the dispensing entity in the specified manner:

Field	Response Format
The dispensing entity and the third-party support entity have mutually agreed that the third-party support entity named above will act on the dispensing entity's behalf in the specified manner.	☐ Yes

Section 3, Question 1B. Questions 1B-1E of this section requests the dispensing entity’s preference for electronic transfer of funds or check and accompanying details for completing payment (banking information or address).

If you indicated in Question 1 of this section that MFP refunds should be sent to your third-party support entity (e.g., PSAO), your third-party support entity will be required to complete Part II of this form to enable the MTF to pass through MFP refunds to that third-party per your instructions. Their information will override the information you provide in Questions 1B-1E. Your financial information that you provide in Questions 1B-1E of this section will be securely stored in the MTF DM and used as needed in case of unforeseen circumstances that interrupt sending payment to your third-party support entity.

Please note that, with respect to payments passed through the MTF PM, the MTF PM’s transfer of the Primary Manufacturer’s authorized MFP refund payment to a dispensing entity shall not in any way indicate or imply that CMS or its MTF Contractors have evaluated or determined that the amount paid by the Primary Manufacturer is sufficient to make the MFP available to the dispensing entity and shall not otherwise discharge the Primary Manufacturer’s statutory obligation to make the MFP available. Neither CMS nor its MTF Contractors will assert independent control over the disposition of deposited payment amounts or direct payment transfers; instead, the MTF Contractors will perform a ministerial function at the behest and direction of the participating Primary Manufacturer with respect to the pass through of the Primary Manufacturer’s funds in the amounts and to the dispensing entities identified by the Primary Manufacturer in its claim-level payment elements.

Because the MTF PM will only pass payments between Primary Manufacturers and dispensing entities, under no circumstances will federal funds be used for these transactions or to resolve or make payment related to disputes that may arise between parties when the MTF PM is utilized, including with respect to nonpayment or insufficient payment by a particular party. Neither CMS nor the MTF Contractors will be responsible for funding or paying the refund amounts owed by the Primary Manufacturer in instances where the Primary Manufacturer does not pay an MFP refund owed to a dispensing entity, including in cases where the Primary Manufacturer may be unable to pay (e.g., bankruptcy, insolvency, etc.). Neither CMS nor its MTF Contractors will accrue any interest on funds held by the MTF PM during the period before the funds are transferred to the dispensing entity (or returned to the Primary Manufacturer in the event of unclaimed funds). The MTF PM will serve only as a mechanism to transfer funds of the Primary Manufacturer to dispensing entities as directed by the Primary Manufacturer in the amounts authorized by the claim-level payment elements transmitted by the Primary Manufacturer and will not collect funds for any other use.

Please select your preference for method of receiving MFP refund payments from Primary Manufacturers using the MTF Payment Module to effectuate the MFP. After indicating your payment preference in Question 1B of this section, please answer either Question 1C or Question 1D, depending on your payment preference. Your responses under this question are required to facilitate the flow of MFP refund payments under a variety of possible circumstances that may arise during implementation of the Program.

Field	Response Format
Dispensing Entity’s MFP Refund Payment Preference	Drop-down menu

Drop-down Menu Options

1	Electronic transfer of funds (default)
2	Paper check

Section 3, Question 1C. If “electronic transfer of funds” was selected, please complete the table to enable electronic transfer of funds. If “paper check” was selected, please skip to Question 1D.

For large chains directly receiving MFP refund payments (i.e., not using a third-party support entity), all MFP refund payments will be directed to the account you provide, below. If your chain has regional subdivisions or associated store locations that require payments to be deposited into a separate bank account, those entities must enroll separately, entering their respective bank accounts.

Bank Name	Bank Account Holder	Bank Account Type	Recipient’s Bank Account Number	Recipient’s Bank Routing Number
Text	Text	Drop-down menu	Text	Text

Drop-down Menu Options

1	Checking
2	Savings

Please enter the bank account holder’s information. This information is required in order for the MTF to validate and transmit payment.

Field	Response Format
Dispensing Entity Federal Tax Identification Number	Text
Dispensing Entity NPI	Text or Prepopulated by MTF
Address Line 1	Text
Address Line 2	Text
City Name	Text
State	Text
Zip	Text

Section 3, Question 1D. If “paper check” was selected, please complete the table to enable receipt of paper checks.

Field	Response Format
Dispensing Entity Federal Tax Identification Number	Text
Dispensing Entity NPI	Text or Prepopulated by MTF
Payment Address Line 1	Text
Payment Address Line 2	Text
City Name	Text
State	Text
Zip Code	Text

Section 3, Question 1E. Confirmation of Information Needed for Electronic Transfer of Funds. To enable electronic transfer of funds, please upload one of the following documents to verify the banking information provided: either (1) voided check for the account listed, which shows the account holder’s name, bank account number, and routing number—ensure that the check is clearly marked as “VOID” across the front; or, (2) letter from bank, printed on official bank letterhead, that confirms the account holder’s name, account number, and routing number—the letter must be signed by a representative of the bank and include their contact information for verification purposes.

[DOCUMENT UPLOAD]

Section 3, Question 2. If you indicated that a third-party support entity will receive MFP refunds and/or ERAs or remittance advice on your behalf in Question 1, please indicate your authorization for the MTF to use and rely on the third-party support entity’s information as reported to NCPDP dataQ Pharmacy Database. Your response will guide how we verify dispensing entity/third-party support entity relationship information. Accordingly, please ensure that your information in NCPDP dataQ Pharmacy Database is correct and up to date.

Field	Response Format
Yes, I acknowledge and agree	☐

Section 3, Question 3. Please indicate whether your dispensing entity is a nonprofit organization. A nonprofit organization is generally defined as an entity that is exempt from federal income tax under Internal Revenue Code Section 501(c). Nonprofit dispensing entities will not receive an IRS Form 1099.

Field	Response Format
Is the dispensing entity a nonprofit organization?	☐ Yes ☐ No

Section 4: Dispensing Entity MFP Refund Payment Instructions for Primary Manufacturers Not Participating in the MTF Payment Module

Section 4, Question 1. Dispensing Entity Acknowledgment of Information Sharing with Primary Manufacturers Not Using the MTF Payment Module.
For Primary Manufacturers that are not utilizing the MTF Payment Module, CMS plans to make available through the MTF DM the dispensing entity’s financial information: preference for electronic transfer of funds or check; bank account information (if dispensing entity prefers MFP refunds to be sent directly to itself via electronic transfer of funds) or payment instructions to a third-party support entity; designated destination for ERAs or remittances; and contact information to support the Primary Manufacturer’s creation and transmission of an ERA or remittance to the dispensing entity. Your information will only be shared with applicable Primary Manufacturers and kept confidential. Please indicate your acknowledgment and acceptance.

Field	Response Format
Yes, I acknowledge and agree	☐

Section 4, Question 2. Confirmation of Dispensing Entity MFP Refund Payment Instructions to a Third-Party Support Entity.

If you indicated in Section 3, Questions 1 and/or 1A that MFP refund payments and/or ERAs or remittance advice should be sent and made available to a third-party support entity, please confirm those details by filling in the table, below. Your entry must match your response in Section 3, Questions 1 and/or 1A. If there is a discrepancy, the system will generate an error and prevent submission. Your third-party support entity’s information will be obtained through their respective enrollment form.

Field	Response Format
Name of third-party support entity to which MFP refund payments should be sent, as directed by the dispensing entity	Text
NCPDP “Payment Center ID” code of third-party support entity to which MFP refund payments should be sent	Text
Name of the third-party support entity to which ERAs or remittance advice should be sent, as directed by the dispensing entity	Text
NCPDP “Remit and Reconciliation ID” code of the third-party support entity to which ERAs or remittance advice should be sent	Text

Section 5: Dispensing Entity Contact Information

Please provide information for two points of contact within the Dispensing Entity. The designated points of contact in this section do not need to match the contacts registered with NCPDP. However, they should be individuals who are knowledgeable about the contents in this form and able to respond any inquiries from CMS or the MTF if clarifications or additional information is needed. Accordingly, please ensure that the designated points of contacts are familiar with the details provided on this form and can provide timely responses.

Instructions

• Both tables should be completed in their totality, with one exception regarding the number of phone numbers.

• Enter the name and title of a contact person who can answer questions about the information submitted on this form.

• For each point of contact, two phone numbers are requested, with one being required. If a point of contact only has one phone number they can be reached at, CMS will accept submissions with only one; if no second phone number, indicate “Not Available” in the relevant field.

Section 5, Question 1. Primary Point of Contact

Field	Response Format
First Name	Text
Last Name	Text
Title	Text
Email Address	Text
Phone Number (1)	Text
Phone Number (2) (optional)	Text

Section 5, Question 2. Secondary Point of Contact

Field	Response Format
First Name	Text
Last Name
Title	Text
Email Address	Text
Phone Number (1)	Text
Phone Number (2) (optional)	Text

Section 6. Dispensing Entity Certification
Please finalize your submission by certifying the completeness and accuracy of the information in sections 1 through 5.

Instruction for Section 6

An individual eligible to certify this submission on behalf of the dispensing entity must be one of the following: (1) the chief executive officer (CEO) of the organization, (2) the chief financial officer (CFO) of the organization, (3) an individual other than a CEO or CFO, who has authority equivalent to a CEO or CFO of the organization, or (4) an individual with the directly delegated authority to perform the certification on behalf of one of the individuals mentioned in (1) through (3).

Certification:

I hereby certify, to the best of my knowledge, that the information being sent to CMS in this submission is complete and accurate, and the submission was prepared in good faith and after reasonable efforts. I reviewed the submission and made a reasonable inquiry regarding its content. I understand the information contained in this submission is being provided to and will be relied upon by CMS to facilitate payment of an MFP retrospective refund on MFP-eligible claims of selected drugs from the Primary Manufacturer to the dispensing entity in accordance with section 1193(a)(3) of the Social Security Act. I also certify that I will timely notify CMS if I become aware that any of the information submitted in this form has changed.

Yes [ ]

No [ ]

Field	Response
Full Name (e-signature)	Text
Date	MM/DD/YYYY

Part II: Third-Party Support Entity Enrollment Questionnaire

Only third-party support entities responsible for central pay and remittance/reconciliation services for their contracted dispensing entities, or those selected by a dispensing entity to receive MFP refunds and/or ERAs/remittance advice on their behalf, as indicated by the dispensing entity in Part I of this form, should complete Part II.

Section 1: Third-Party Support Entity MTF DM User Roles

Section 1 requires the entity completing the third-party support entity enrollment form to assign MTF DM user roles for any individuals they wish to have user access to the MTF portal.

• Authorized Signatory Official: An appointed individual of third-party support entity with authority to legally bind that organization in agreements, represent the organization in an official capacity, and act on behalf of an organization. To be eligible, the Authorized Signatory Official must meet one or more of the following criteria: (1) serve as the Chief Executive Officer (CEO), where the individual has been duly appointed by the organization’s board or other governing body; (2) serve as the Chief Financial Officer (CFO), where the individual has been duly appointed by the organization’s board or other governing body; (3) serve in a role other than as the CEO or CFO, where the individual has authority that is equivalent to a CEO or CFO; or (4) serve in a role, where the individual has been granted directly delegated authority to legally bind the organization on behalf of one of the individuals previously noted in (1)-(3).

• Access Manager: An individual, designated by the Authorized Signatory Official of the third-party support entity, authorized to act on behalf of the organization to view, modify, submit, and certify the completeness and accuracy of the information on this form and to submit complaints and disputes in the MTF DM on behalf of the organization.

• Staff End User: An individual, designated by the Access Manager of the third-party support entity, authorized to perform more limited tasks, such as view and download information in the MTF DM and submit complaints and disputes in the MTF DM on behalf of the organization.

Instructions

• Review the table below and ensure each individual’s user role is accurate.

Drop-down Menu	Response Format – Full Name	Response Format – Email Address
[Drop-down Menu]	Prepopulated by MTF	Prepopulated by MTF
[Drop-down Menu]	Prepopulated by MTF	Prepopulated by MTF
[Drop-down Menu]	Prepopulated by MTF	Prepopulated by MTF
[Drop-down Menu]	Prepopulated by MTF	Prepopulated by MTF

Section 2: Third-Party Support Entity Identification Information

Section 2 requires identifying information about the third-party support entity acting on behalf of a dispensing entity enrolled in the MTF DM, including the third-party support entity’s federally issued identifying information and demographic, geographic, and relationship information for verification purposes to enable enrollment efficiencies in the MTF DM.

Instructions

• Third-party support entities acting on behalf of dispensing entities enrolled in the MTF DM should answer all questions. If a question is not applicable, please indicate as such in the corresponding text field.

Section 2, Question 1. Complete the following table for your organization. If mailing address and business address are the same, please indicate that in the text box rather than filling out the same address twice.

Legal Business Name	Doing Business As (DBA) Name	Mailing Address	Business Address	Federal Tax Identification Number
Text	Text	Text	Text	Text

Section 2, Question 2. Please review the following National Council for Prescription Drug Programs (NCPDP) identification number(s) for verification purposes.

Field	Response Format
NCPDP “Payment Center ID”	Prepopulated by MTF, if applicable
NCPDP “Remit and Reconciliation ID”	Prepopulated by MTF, if applicable

Section 3: Third-Party Support Entity Financial Information

Financial information and account details should be provided by third-party support entities authorized to receive MFP refund payment from Primary Manufacturers through the MTF PM. This information may also be necessary for establishing accurate remittance advices or ERAs.

Instructions

• This section is applicable to third-party support entities that will receive MFP refund payments on behalf of a dispensing entity (i.e., entities with an NCPDP “Payment Center ID”). Third-party support entities that will receive ERAs or remittances on behalf of a dispensing entity (i.e., entities with an NCDCP “Remit and Reconciliation ID”) are not required to provide their financial information and may skip this section.

• In Question 1 of this section, please indicate your organization’s preference to receive either a paper check or an electronic transfer of funds. If electronic transfer of funds is selected, please enter the required financial information to enable receipt of electronic transfer of funds under Question 1A. If paper check is selected, please enter the required payment address information under Question 1B.

• In completing this section, please note the following:

  • The financial institution’s name must be the legal business name of that financial institution.

  • The account to which electronic transfer of funds payments is made must bear the account holder’s name and legal business name.

  • Account number should include applicable leading zeros.

• The third-party support entity is responsible for maintaining the accuracy of information in this section and reporting any changes over time. Upon any change to the information in this section, the enrollee should update the information in this form via the MTF DM. In particular, maintaining up to date information regarding banking information, and arrangements between a dispensing entity and a third-party support entity managing MFP refund payments on a dispensing entity’s behalf is crucial to maintaining the flow of MFP refunds.

• Under Question 1C of this section, please submit a voided check or a letter on the bank’s letterhead for verification purposes. This helps to ensure the accuracy of account details and prevents errors in payment processing. Only one type of documentation is needed. When submitting the banking verification documentation, it should contain the name on the account (account holder’s name), routing number, account number, and account type. If submitting bank letterhead, the bank officer’s name and signature is also required. NOTE: Supporting bank documents must be in the third-party support entity’s legal business name only.

• Question 2 concerns tax reporting information. Nonprofit third-party support entities will not receive an IRS Form 1099.

Section 3, Question 1. While the MTF will keep your financial information on file, whether you will be the recipient of MFP refund payments depends on the dispensing entity’s response in Part I, Section 3 of this form. Accordingly, select a preference. After indicating your preference, please answer either Question 1A or Question 1B.

Field	Response Format
Preference	Drop-down menu

Drop-down Menu Options

1	Electronic transfer of funds (default)
2	Paper check

Section 3, Question 1A. If “electronic transfer of funds” was selected in response to Question 1, please complete the table to enable electronic transfer of funds. If “paper check” was selected, please skip to Question 1B.

Bank Name	Bank Account Holder	Bank Account Type	Recipient’s Bank Account Number	Recipient’s Bank Routing Number
Text	Text	Drop-down menu	Text	Text

Drop-down Menu Options

1	Checking
2	Savings

Section 3, Question 1B. If “paper check” was selected in response to Question 1, please complete the table to enable receipt of paper checks.

Field	Response Format
Payment Address	Text
Remittance Address	Text

Section 3, Question 1C. Confirmation of Information Needed for Electronic Transfer of Funds. To verify the banking information provided, please upload one of the following documents to your submission: either (1) voided check for the account listed, which shows the account holder’s name, bank account number, and routing number—ensure that the check is clearly marked as “VOID” across the front; or, (2) letter from bank, printed on official bank letterhead, that confirms the account holder’s name, account number, and routing number—the letter must be signed by a representative of the bank and include their contact information for verification purposes.

[DOCUMENT UPLOAD]

Section 3, Question 2. Please indicate whether your third-party support entity is a nonprofit organization. A nonprofit organization is generally defined as an entity that is exempt from federal income tax under Internal Revenue Code Section 501(c). Nonprofit third-party support entities will not receive an IRS Form 1099.

Field	Response Format
Is the third-party support entity a nonprofit organization?	☐ Yes ☐ No

Section 4: Third-Party Support Entity Contact Information

Please provide information for two points of contact within the third-party support entity. The designated points of contact in this section should be individuals who are knowledgeable about the contents in this form and able to respond any inquiries from CMS or the MTF if clarifications or additional information is needed. Accordingly, please ensure that the designated points of contacts are familiar with the details provided on this form and can provide timely responses.

Instructions

• Both tables should be completed in their totality, with one exception regarding the number of phone numbers.

• Enter the name and title of a contact person who can answer questions about the information submitted on this form.

• If a point of contact only has one phone number they can be reached at, CMS will accept submissions with only one; if no second phone number, indicate “Not Available” using in the relevant field.

Section 4, Question 1. Primary Point of Contact

Field	Response Format
First Name	Text
Last Name	Text
Title	Text
Email Address	Text
Phone Number (1)	Text
Phone Number (2) (optional)	Text

Section 4, Question 2. Secondary Point of Contact

Field	Response Format
First Name	Text
Last Name	Text
Title	Text
Email Address	Text
Phone Number (1)	Text
Phone Number (2) (optional)	Text

Section 5. Third-Party Support Entity Certification
Please finalize your submission by certifying the completeness and accuracy of the information in sections 1 through 4.

Instruction for Section 5

An individual eligible to certify this submission on behalf of the third-party support entity must be one of the following: (1) the chief executive officer (CEO) of the organization, (2) the chief financial officer (CFO) of the organization, (3) an individual other than a CEO or CFO who has authority equivalent to a CEO or CFO of the organization, or (4) an individual directly delegated authority to perform the certification on behalf of one of the individuals mentioned in (1) through (3).

Certification:

I hereby certify, to the best of my knowledge, that the information being sent to CMS in this submission is complete and accurate, and the submission was prepared in good faith and after reasonable efforts. I reviewed the submission and made a reasonable inquiry regarding its content. I understand the information contained in this submission is being provided to and will be relied upon by CMS to facilitate payment of an MFP retrospective refund on MFP-eligible claims of selected drugs from the Primary Manufacturer to the dispensing entity in accordance with section 1193(a)(3) of the Social Security Act. I also certify that I will timely notify CMS if I become aware that any of the information submitted in this form has changed.

Yes [ ]

No [ ]

Field	Response
Full Name (e-Signature)	Text
Date	MM/DD/YYYY

1 CMS, Final Rule, “Medicare and Medicaid Programs: Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly,” April 15, 2025 (90 Fed. Reg. 15834). See: https://www.federalregister.gov/documents/2025/04/15/2025-06008/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare.

19