CMS-367a, 367b, 36 CMS Record Specification and Rebate Agreement

CMS RECORD SPECIFICATION

DDR QUARTERLY PRICING DATA

TEXT FILE FOR TRANSFER TO CMS

Source: Drug Manufacturers

Target: CMS

Field	Size	Position	Remarks
Record ID	1	1 - 1	Constant of “Q”
Labeler Code	5	2 - 6	NDC #1
Product Code	4	7 - 10	NDC #2
Package Size	2	11 – 12	NDC #3
Period Covered	5	13 – 17	QYYYY (Qtr/Yr)
Average Mfr Price	12	18 – 29	99999.999999
Best Price	12	30 – 41	99999.999999
Nominal Price	9	42 – 50	999999999
Customary Prompt Pay Disc.	9	51 – 59	999999999
5i Threshold	1	60-60	Y or N or X

CMS-367a (Exp. )

OMB No. 0938-0578

CMS RECORD SPECIFICATION

DDR MONTHLY PRICING DATA

TEXT FILE FOR TRANSFER TO CMS

Source: Drug Manufacturers

Target: CMS

Field	Size	Position	Remarks
Record ID	1	1 - 1	Constant of “M”
Labeler Code	5	2 - 6	NDC #1
Product Code	4	7 - 10	NDC #2
Package Size	2	11 - 12	NDC #3
Month	2	13 – 14	MM
Year	4	15 – 18	YYYY
Average Mfr Price (AMP)	12	19 – 30	99999.999999
AMP Unit	14	31 – 44	99999999999.99
5i Threshold	1	45 - 45	Y or N or X
Filler	15	46 – 60	spaces

CMS-367b (Exp. )

OMB No. 0938-0578

CMS RECORD SPECIFICATION

DDR DRUG PRODUCT DATA

TEXT FILE FOR TRANFER TO CMS

Source: Drug Manufacturers

Target: CMS

Field	Size	Position	Remarks
Record ID	1	1 – 1	Constant of “P”
Labeler Code	5	2 – 6	NDC #1
Product Code	4	7 – 10	NDC #2
Package Size Code	2	11 - 12	NDC #3
Drug Category	1	13 - 13	See Data Element Definitions
Unit Type	3	14 - 16	See Data Element Definitions
FDA Approval Date	8	17 - 24	MMDDYYYY
FDA Thera. Eq. Code	2	25 - 26	See Data Element Definitions
Market Date	8	27 - 34	MMDDYYYY
Termination Date	8	35 - 42	MMDDYYYY
DESI Indicator	1	43 - 43	See Data Element Definitions
Drug Type Indicator	1	44 - 44	See Data Element Definitions
OBRA ‘90 Baseline AMP	12	45 - 56	99999.999999
Units Per Pkg Size	11	57 - 67	9999999.999
FDA Product Name	63	68 – 130	FDA Drug Listing Name
Package Size Intro. Date	8	131 - 138	MMDDYYYY
Purchased Product Date	8	139 - 146	MMDDYYYY
ACA Base AMP	12	147 - 158	99999.999999
5i Drug Indicator	1	159 - 159	Y or N
5i Route of Administration	3	160 - 162	See Data Element Definitions
Line Extension Indicator	1	163 - 163	See Data Element Definitions
Initial Brand Name Listed NDC	9	164 - 172	See Data Element Definitions
COD Status	2	173 - 174	See Data Element Definitions
FDA Approval Number	30	175 - 204	See Data Element Definitions
Filler	6	205 - 210	Spaces

CMS-367c (Exp. )

OMB No. 0938-0578

ENCLOSURE B (PAGE 1 OF 2)

SUPPLEMENTAL DATA SHEET

LABELER CODE

LABELER NAME

LEGAL CONTACT

NAME OF CONTACT

AREA PHONE NUMBER EXTENSION

NAME OF CORPORATION

STREET ADDRESS

CITY STATE ZIP CODE

EMAIL ADDRESS (Optional)

INVOICE CONTACT

NAME OF CONTACT

AREA PHONE NUMBER EXTENSION

NAME OF CORPORATION

STREET ADDRESS

CITY STATE ZIP CODE

EMAIL ADDRESS (Optional)

CMS-367d (Exp. )

OMB No. 0938-0578

ENCLOSURE B (PAGE 2 OF 2)

SUPPLEMENTAL DATA SHEET

LABELER CODE

LABELER NAME

TECHNICAL CONTACT

NAME OF CONTACT

PHONE NUMBER EXTENSION

FAX NUMBER

NAME OF CORPORATION

STREET ADDRESS

CITY STATE ZIP CODE

EMAIL ADDRESS (should match DDR user account email address)

Notes:

• If you are amending existing contact information for more than one labeler, provide a form for each labeler code. Do not send a copy of your rebate agreement(s) with this form.

• It is your responsibility to ensure that your contact information is the same for all labeler codes in the MDR program.

CMS-367d (Exp. )

OMB No. 0938-0578