Exclusive insights from Ned Milenkovich, PharmD, JD, help parse out what pharmacists should be aware of as most favored nation initiatives are agreed upon with the federal government.
Over the past 5 months, a litany of pharmaceutical companies has reached agreements with the Trump Administration to voluntarily reduce list prices for key drugs in their pipelines for patients on Medicaid and align with a most favored nation (MFN) drug pricing model for newly launched drugs. These actions could help lower drug prices in the United States for blockbuster treatments such as semaglutide (Ozempic, Wegovy; Novo Nordisk), apixaban (Eliquis; Bristol Myers Squibb), tirzepatide (Mounjaro, Zepbound; Eli Lilly), and others to prices comparable with often-lower amounts in other high-income countries.1,2
Pharmacists need to know key aspects of MFN’s impacts on their practice and their patients, as these changes can significantly affect “what patients pay and whether they can get the drug,” according to Ned Milenkovich, PharmD, JD, principal at Much Shelist, P.C., and member of the Pharmacy Times Editorial Advisory Board. In an interview, Milenkovich said pharmacists can expect changes to their workflows when MFN pricing comes into effect, including more formulary checks and reprocessing, more prior authorizations, and possible supply disruptions.
It is critical for pharmacists to take the time to educate themselves on MFN. Milenkovich noted that preparing practical counseling points for patients with concerns about coverage changes, ensuring operational readiness, and keeping the focus on “what patients feel at the counter” are critical components of effective pharmacy care in this new era of drug pricing.
“These initiatives could change what patients pay and how pharmacies operate,” Milenkovich said.
Representatives from Pfizer were the first to announce an agreement with the Trump Administration to lower their prices and adhere to MFN. Pfizer agreed to reduce prices on a large majority of the company’s primary care treatments. The company also said they would reduce prices on select specialty brands, with total savings ranging from an average of 50% to as high as 85%.1
MFN is a pricing approach in which an entity—in this case the United States—is seeking drug prices that are tied to the lowest prices a manufacturer offers in other countries, according to Milenkovich. The US is using MFN as “negotiating leverage,” Milenkovich said, in which manufacturers that agree to concessions—such as reducing prices through expanding direct-to-consumer (DTC) offerings for key drugs—can gain support for continued US manufacturing and relaxation of financial penalties.
The Trump Administration has sought to lower US drug prices by pressuring pharmaceutical companies to adhere to MFN policies. In a May 2025 executive order, the White House threatened strict regulations, Federal Trade Commission investigations, and further executive action—including tariffs—to force price reductions if manufacturers did not voluntarily do so. President Donald Trump reinforced these demands in a July letter to 17 manufacturer CEOs, specifically requesting the following policies:1
These tariffs, announced in October 2025, were based on alleged violations of Section 232 of the Trade Expansion Act (often called Section 232 tariffs by drug manufacturers) and were intended to be levied on branded or patented drugs imported to the US. In exchange for the voluntary price reductions laid out in the May executive order, many pharmaceutical companies have been granted almost universal grace periods on those tariffs. The companies have also agreed to increase their manufacturing capabilities in the United States, another major demand of the White House. Furthermore, in a major development for increased drug access, the companies are set to offer major treatments on the yet-to-be-launched TrumpRx direct-to-consumer (DTC) purchasing platform, along with expanding their own DTC drug offerings.1,3
Novo Nordisk centered their announcement around their blockbuster weight loss drug, semaglutide. By expanding access through TrumpRx, Novo Nordisk will offer semaglutide at reduced prices to Medicare Part D and Medicaid patients.5
MFN has the potential to upend pharmacy practice, directly impacting the cost and availability of drugs and pharmacy workflows with little preparation time, according to Milenkovich. Uncertainty reigns supreme in the current situation, especially when it comes to patients’ out-of-pocket costs. These costs could be reduced if savings hit the point of sale, or they may remain the same if savings are mainly rebate-driven. However, costs could increase for some due to formulary shifts or added utilization controls. In addition, unexpected fulfillment delays due to MFN could function as an access barrier, even if a prescription is covered, Milenkovich explained.
Confusion may also be sown because, although companies have agreed to offer steep discounts through their own DTC channels, list price increases are still occurring for many medications. In many cases, these price hikes are occurring for drugs produced by manufacturers striking MFN agreements with the Trump Administration. In the interview, Milenkovich outlined the situation by offering an analogy: “Think of it as 2 pricing tracks at once.”4
“Direct-channel discounts are targeted and don’t always change the prices pharmacies bill against, while list prices can still rise because rebates, contracts, and patient coinsurance/deductibles are often tied to list price,” he continued. “For counseling, focus on the patient’s point-of-sale cost and coverage for each fill, and be ready with alternatives or assistance if costs spike.”
EMD Serono announced that they will offer DTC sales of its full portfolio of IVF therapies, including follitropin alfa injection (Gonal-f), choriogonadotropin alfa injection (Ovidrel), and cetrorelix acetate for injection (Cetrotide) to patients with prescriptions at significantly reduced prices. When all 3 therapies are used together in a typical IVF protocol, the company expects patients to receive an 84% discount off list prices.6
Meanwhile, pharmacists can take concrete steps to prepare for these unknowns. Milenkovich highlights timing, scope, and supply/availability as major areas of concern that can “quickly affect access and what patients pay.” Tariff enforcement, coverage reactions, and patient confusion are also salient considerations that pharmacists should factor into staff education and operational planning. Patients may have a multitude of questions as MFN impacts price variability from fill to fill, which Milenkovich says “requires tighter counseling and documentation.”
Important steps should be taken in the near term to ensure operational readiness, according to Milenkovich. Pharmacists should “tighten real-time benefit and formulary checks” while ensuring templates are ready for pharmacists to counsel patients on prescriber outreach, prior authorization, and alternative recommendations. They should also be monitoring acquisition cost versus reimbursement more often while taking steps to strengthen supply contingencies, like alternating suppliers and setting up backorder processes.
On the patient education front, Milenkovich highlights the ability for pharmacists to proactively set expectations for patients that prices or coverage can change and encourage checking the cost of medications before pickup. They can also discuss lower-cost options with patients, like generics or therapeutic alternatives. If cost is a barrier for a patient, the pharmacist can assist with programs and explain potential exception requests and appeals.
Milenkovich outlined a few practical considerations for pharmacists as they navigate the unknowns of MFN:
“Standardize team counseling language and handoffs so every patient gets the same clear explanation, options, and timelines—supporting trust when prices and access shift unexpectedly,” Milenkovich concluded.
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