State Drug Rebate (Medicaid)

MEDICAID DRUG REBATE PROGRAM

STATE INVOICE RECORD FORMAT

(Form CMS-R-144)

Effective: December 1, 2011

Source: State Agencies

Target: CMS & Manufacturers

Field	Size	Position	Remarks
*Record ID	4	1 – 4	Constant of “FFSU” or “MCOU”
State Code	2	5 – 6	P.O. Abbreviation
Labeler Code	5	7 – 11	NDC 1
Product Code	4	12 – 15	NDC 2
Package Size Code	2	16 – 17	NDC 3
Period Covered	5	18 – 22	QYYYY
Product FDA Reg. Name	10	23 – 32	Product name as appears on FDA listing form. (1st 10 characters)
Unit Rebate Amount	12	33 – 44	9(5).9(6)
Units Reimbursed	15	45 – 59	9(11).999
Rebate Amount Claimed	12	60 – 71	9(9).99
Number of Prescriptions	8	72 – 79	9(8)
M’Caid Amount Reimb.	13	80 – 92	9(10).99
Non-M’Caid Amount Reimb.	13	93 - 105	9(10).99
Total Amt Reimbursed	14	106 – 119	9(11).99
*Filler	1	120 – 120

All fields with decimals now require actual decimal

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