Form CMS-R-144 Medicaid Drug Rebate Invoice

DATE:

/
/
MM DD YYYY

STATE OF

Source: State Agencies
Target: Manufacturers
Manufacturer:
Address:
City:

NDC
Number

PAGE
(Medicaid Agency)

OF ____

MEDICAID DRUG REBATE INVOICE
STATE CODE:
INVOICE NO.: _____
PERIOD COVERED:_______(QYYYY)
State:

Drug
Name

Unit
Rebate
Amount

Zip: ______

Record ID

Units
Reimbursed

Rebate
Amount
Claimed

No. of
Scripts

Medicaid
Amount
Reimbursed

NonMedicaid
Amount
Reimbursed

Total
Amount
Reimbursed

Correction
Flag

TOTALS:

*Please remit this amount to:
Address:
Attn:
Form CMS-R-144 (Exp. 11/30/14)
OMB No. 0938-0582

(Medicaid Agency)