Form #12 Form #12 Pharmacies questionnaire

Form Approved
OMB No. 0935-0118
Exp. Date XX/XX/20XX

MEDICAL EXPENDITURE PANEL SURVEY

MEDICAL PROVIDER COMPONENT

DATA FORM

FOR

PHARMACIES

for

REFERENCE YEAR 2009

VERSION 2.0

Revision History

Version	Author/Title	Date	Comments
1.0	Multiple RTI and SSS authors	12/23/08
2.0	Multiple RTI and SSS authors	04/01/09	Changes from Version 1.0 marked in yellow highlighting

Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Q1. Date Filled:   /      /09

Q2. Prescription information will be identified using:  NDC (GO TO Q2a)

 Drug Name, Strength/Unit, and Dosage Form

TRY TO OBTAIN NDC. USE DRUG NAME (GO TO Q2b)

ONLY IF NDC NOT AVAILABLE.

Q2a. NDC: -- (GO TO Q3a/b)

IF DRUG IS A COMPOUND ENTER

99999-9999-96

Q2b. Drug Name:

Q2c/d. Strength/Unit: Strength: Unit:

Q2e. Dosage Form:

IF ITEM IS A PRODUCT RECORD THE

ITEM NAME AS THE DOSAGE FORM

(E.G., IF PROFILE SAYS BACK BRACE,

DOSAGE FORM SHOULD BE BRACE).

DO NOT RECORD CONTAINERS

(VIALS, BOTTLES, TUBES, ETC.)

OR EACH (EA) AS DOSAGE FORMS.

Q3a/b. Quantity/Unit: Quantity: Unit:

NOTE 1: QUANTITY MUST BE THE CONTENTS

OF A CONTAINER, NOT THE NUMBER

OF CONTAINERS. EXCEPTION: IF AN NDC IS

GIVEN THE QUANTITY OF AN EPIPEN MAY BE

ACCEPTED AS THE NUMBER OF EPIPENS

(VERSUS THE QUANTITY OF THE CONTENTS

OF THE EPIPEN).

NOTE 2: ACCEPT A QUANTITY OF 1 OR 2 FOR A DEVICE.

NOTE 3: ACCEPT A QUANTITY OF 1 OR 2 FOR PILLS,

UNLESS IT LOOKS LIKE THE QUANTITY IS

FOR ONE OR TWO DOSEPAKS,

WHICH MAY CONTAIN MULTIPLE PILLS

(THEN NEED TO ASK FOR THE QUANTITY OF

TABLETS, CAPSULES, ETC. THAT THE DOSEPAK

CONTAINS).

NOTE 4: FOR OINTMENTS, CREAMS, DROPS, LIQUID,

FILLED SYRINGES (EXCEPT EPIPENS) AND

OTHER DOSAGE FORMS THAT NEED A QUANTITY UNIT,

ASK FOR THE QUANTITY OF THE CONTENTS.

Q4. Days Supplied

Q5. Patient Payment: $ .

ALLOW AMOUNTS FROM $0 TO $500.

Q6. Type of 3^rd Party Payer

 NONE

IF PATIENT PAYMENT WAS $1 OR LESS,

EXPECT THE 3^rd PARTY PAYER TO BE A

PUBLIC PROGRAM, E.G., MEDICAID OR

OTHER STATE/LOCAL GOVT, ETC.

Q7. 3^rd Party Payment: $ .

ALLOW AMOUNTS FROM $0 TO $5,000.

 NEXT PRESCRIPTION

[WHEN THIS BOX IS CHECKED, THE SAME QUESTIONS FOR A NEW PRESCRIPTION WILL BE

AUTOMATICALLY GENERATED BY THE SYSTEM]

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