Form CMS-10241 State Payment and Utilization Rates and Performance Rank

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Overview

Background
General Information
Utilization Data
Unit Prices

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Sheet 1: Background

Background

Legislative Mandate for Data Request

Section 6001 (f) of the Deficit Reduction Act (DRA) requires CMS to contract with a vendor to conduct a monthly national survey of retail prescription drug prices and to report the prices to the States. These national average prices will be used as a benchmark by the States for the management of their prescription drug programs.

The law requires that the States submit pricing information for the 50 most prescribed drugs so that the States' prices can be compared to the national average prices obtained from the survey. The States' pricing information will be compared and the States will be ranked. The law also requires that States report their drug utilization rates for non-innovator multiple-source (generic) drugs, their payment rates under their State plan, and their dispensing fees.

This template has been developed to facilitate data collection from the States.

This Excel spreadsheet contains four (4) tabs: Background, General Information, Utilization Data, and Unit Prices. The first tab (this tab) provides the legislative background and mandate and requires no input from the States. The remaining tabs each have instructions for filling in the requested information.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average (15 hours) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850

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Sheet 2: General Information

State	Pricing Source Formula	Dispensing Fee Schedule	Reference Price Source
			Pricing Compendia	Other Pricing Source	Pricing Source Not Listed

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Sheet 3: Utilization Data

Single-Source Totals (S)		Non-Innovator Multi-Source Totals (N)		Innovator Multi-Source Totals (I)
Number of Prescriptions	Reimbursement Amount	Number of Prescriptions	Reimbursement Amount	Number of Prescriptions	Reimbursement Amount

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Sheet 4: Unit Prices

Rank	NDC11	Name	Strength	MMIS Pricing Unit	EAC Unit Price	EAC Pricing Source					Dispensing Fee
						AWP	WAC	AMP	RPS	OTHER
1	00300304613	PREVACID	30MG			0	0	0	0	0
2	00186504031	NEXIUM	40MG				0	0	0
3	00006011731	SINGULAIR	10MG				0	0	0	0
4	00173069600	ADVAIR DISKUS	250-50MCG			0			0
5	00006027531	SINGULAIR	5MG						0
6	00310027210	SEROQUEL	200MG						0
7	50458030006	RISPERDAL	1MG						0
8	00310027110	SEROQUEL	100MG						0
9	00006071131	SINGULAIR	4MG						0
10	00071015623	LIPITOR	20MG						0
11	00456202001	LEXAPRO	20MG						0
12	00088222033	LANTUS	1000U/10ML						0
13	50458032006	RISPERDAL	2MG						0
14	00310027460	SEROQUEL	300MG						0
15	00456201001	LEXAPRO	10MG						0
16	50458030206	RISPERDAL	0.5MG						0
17	00024542131	AMBIEN	10MG						0
18	00310027510	SEROQUEL	25MG						0
19	00071015523	LIPITOR	10MG						0
20	00173069500	ADVAIR DISKUS	100-50MCG						0
21	59148000813	ABILIFY	10MG						0
22	59148000713	ABILIFY	5MG						0
23	00173064255	LAMICTAL	100MG						0
24	00069154068	NORVASC	10MG						0
25	00008084181	PROTONIX	40MG						0
26	00045064165	TOPAMAX	100MG						0
27	50458033006	RISPERDAL	3MG						0
28	00002411730	ZYPREXA	10MG						0
29	00002323730	CYMBALTA	60MG						0
30	00173069700	ADVAIR DISKUS	500-50MCG						0
31	59148000913	ABILIFY	15MG						0
32	00071015723	LIPITOR	40MG						0
33	00002442030	ZYPREXA	20MG						0
34	00069553047	ZYRTEC	5MG/5ML						0
35	00024552131	AMBIEN CR	12.5MG						0
36	00069153068	NORVASC	5MG						0
37	00069073166	ZYRTEC	10MG						0
38	00049399060	GEODON	80MG						0
39	61958070101	TRUVADA	200-300MG						0
40	00006003144	FOSAMAX	70MG						0
41	00062192015	ORTHO EVRA 3	20-150MCG/24HR						0
42	00078033705	TRILEPTAL	300MG						0
43	00597007537	SPIRIVA HANDIHALER	18MCG						0
44	00002441530	ZYPREXA	15MG						0
45	59148001013	ABILIFY	20MG						0
46	00029315920	AVANDIA	4MG						0
47	59148001113	ABILIFY	30MG						0
48	64764030114	ACTOS	30MG			0			0
49	50474059540	KEPPRA	500MG						0
50	00045152550	LEVAQUIN	500MG						0