State Drug Rebate (Medicaid)

MEDICAID DRUG REBATE PROGRAM

STATE INVOICE FIELD DEFINITIONS

(Form CMS-R-144)

Effective December 1, 2011

Data Fields

Record ID: Constant “FFSU” or “MCOU”. The FFSU Record ID indicates that the information for this NDC represents a Fee-for-Service Utilization record. The MCOU Record ID indicates that the information for this NDC represents a Managed Care Organization Utilization record. Valid Values: 4Q2009 and earlier = Constant record ID of FFSU. 1Q2010 and beyond = FFSU & MCOU.

NOTE: Per the Affordable Care Act, MCO utilization data cannot be reported for periods prior to first quarter 2010.

NOTE: Beginning with first quarter 2010, CMS will accept one utilization record per NDC per quarter/year combination per record ID type (FFSU vs. MCOU).

State Code: Two-character post office abbreviation for the state. Alphabetic, 2 digits.

Labeler Code: First segment of National Drug Code (NDC 1) that identifies the manufacturer, labeler, relabeler, packager, repackager or distributor of the drug. Numeric values only, 5-digit field, right justified and zero-filled for 4-digit labeler codes.

Product Code: Second segment of NDC. Alphanumeric values, 4-digit field, right justified, zero-filled for 3-digit product codes.

Package Size Code: Third segment of NDC. Alphanumeric values, 2-digit field, right justified, zero-filled for 1-digit package size codes.

Period Covered: The calendar quarter and year in which the 11-digit NDC was paid for by the State . Numeric, 5-digit field, QYYYY

Valid values for Q:

1 = January 1 – March 31

2 = April 1 – June 30

3 = July 1 – September 30

4 = October 1 – December 31

Valid values for YYYY: 4-digit calendar year covered.

Product FDA Reg. Name: (Abbreviated) – First 10 characters of product name as approved by the FDA. Alphanumeric values, 10 digits.

Unit Rebate Amount: The CMS calculated amount (per reported unit type) to be multiplied by Units Reimbursed by the state during the period covered. Numeric values, 12 digits: 5 whole numbers, 6 decimal places, and a decimal point.

Units Reimbursed: The number of FFS or MCO units (based on Unit Type and Record ID) of the drug (11-digit NDC level) reimbursed by the state during the period covered. Numeric values, 15 digits: 11 whole numbers, 3 decimal places and a decimal point.

Rebate Amount Claimed: The rebate amount that the State Agency claims it is owed by the labeler for the period covered for this (11-digit NDC) FFS or MCO drug. It is calculated by multiplying the FFS or MCO units reimbursed by the rebate amount per unit. Numeric values, 12 digits: 9 whole numbers, 2 decimal places and a decimal point.

Number of Prescriptions: The number of FFS or MCO prescriptions reimbursed (by the Medicaid Program ONLY) to pharmacies for the (11-digit NDC) drug during the period covered. Numeric values, 8 digits, whole numbers only.

M’caid Amount Reimb: Medicaid Amount Reimbursed – The amount reimbursed (by the Medicaid Program ONLY) to pharmacies for the (11-digit NDC) FFS or MCO drug in the period covered. Numeric values, 13 digits: 10 whole numbers, 2 decimal places and a decimal point.

Non-M’caid Amount Reimb: Non-Medicaid Amount Reimbursed – The amount reimbursed (by non-Medicaid entities) to pharmacies for the (11-digit NDC) FFS or MCO drug in the period covered. The Non-Medicaid Amount Reimbursed includes any reimbursement amount for which the state is not eligible for Federal Matching Funds. Numeric values, 13 digits: 10 whole numbers, 2 decimal places and a decimal point.

Total Amount Reimbursed: The FFS or MCO total amount reimbursed by both Medicaid and non-Medicaid entities to pharmacies for the (11-digit NDC) drug in the period covered (two previous fields added together). This total is not reduced or affected by Medicaid rebates paid to the state. This amount represents both the Federal and State Reimbursement and is inclusive of dispensing fees. Numeric values, 14 digits: 11 whole numbers, 2 decimal places and a decimal point.

Filler: 1 position filler.

This field previously contained the Correction Flag Indictor which specified whether the record was the first submission (0=original record) or whether it is a correction (1 = correction) to an existing record. The CMS Medicaid Drug Rebate (MDR) system makes the determination: if the record does not exist within the MDR system, it processes as an original; if the record does exist within the MDR system, it processes as a correction.