CMS-367 Record File Specification

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

CMS-367a (Exp. 09/30/2016 )

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	12	19 – 30	99999.999999
AMP Units	14	31 – 44	99999999999.99
5i Threshold	1	45 - 45	Y, N, X, or Z

CMS-367b (Exp. 09/30/2016)

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
Drug Type Indicator	1	43 – 43	See Data Element Definitions
OBRA’90 Baseline AMP	12	44 – 55	99999.999999
Units Per Pkg Size	11	56 – 66	9999999.999
FDA Product Name	63	67 – 129	FDA Product Name
DRA Baseline AMP	12	130 – 141	99999.999999
Package Size Intro Date	8	142 – 149	MMDDYYYY
Purchased Product Date	8	150 – 157	MMDDYYYY
5i Drug Indicator	1	158 – 158	See Data Element Definitions
5i Route of Administration	3	159 – 161	See Data Element Definitions
ACA Baseline AMP	12	162 - 173	99999.999999
COD Status	2	174 – 175	See Data Element Definitions
FDA Appl. No./OTC Mono. No.	7	176 – 182	See Data Element Definitions
*Reactivation Date	*n/a	*n/a	*This field may only be submitted online via DDR. See Data Element Definitions

CMS-367c (Exp. 09/30/2016)

OMB No. 0938-0578

MEDICAID DRUG REBATE AGREEMENT ENCLOSURE B (PAGE 1 OF 2) SUPPLEMENTAL DATA SHEET
LABELER CODE (as assigned by FDA)
LABELER NAME (Corporate name associated with labeler code)
LEGAL CONTACT – Person to contact for legal issues concerning the rebate agreement
NAME OF CONTACT
	AREA PHONE NUMBER EXTENSION
EMAIL ADDRESS: ______________________________
NAME OF CORPORATION
STREET ADDRESS
CITY	STATE		ZIP CODE
INVOICE CONTACT – Person responsible for processing invoice utilization data
NAME OF CONTACT
	AREA PHONE NUMBER EXTENSION
EMAIL ADDRESS: ______________________________
NAME OF CORPORATION
STREET ADDRESS
CITY	STATE		ZIP CODE

Note: This sheet is to be returned with the signed rebate agreement. If more than one labeler code, attach one sheet for each code.

CMS-367d (Exp. 09/30/2016)

OMB No. 0938-0578

MEDICAID DRUG REBATE AGREEMENT ENCLOSURE B (PAGE 2 OF 2) SUPPLEMENTAL DATA SHEET
LABELER CODE (as assigned by FDA)
LABELER NAME (Corporate name associated with labeler code)
TECHNICAL CONTACT – Person responsible for sending and receiving data
NAME OF CONTACT
	AREA PHONE NUMBER EXTENSION
FAX # ______________________________
EMAIL ADDRESS: ______________________________
NAME OF CORPORATION
STREET ADDRESS
CITY	STATE		ZIP CODE

Note: This sheet is to be returned with the signed rebate agreement. If more than one labeler code, attach one sheet for each code.

CMS-367d (Exp. 09/30/2016)

OMB No. 0938-0578