Form CMS-10241 Annual State Report and Annual State Performance Ranking

Survey of Retail Prices: Payment and Utilization Rates, and Performance Rankings (CMS-10241)

Copy of CMS-10241-CMSStatesAnalysisdatacollectiontemplate v4(PART I).xls

Annual State Report and Annual State Performance Rankings (CMS-10241)

OMB: 0938-1041

Document [xlsx]
Download: xlsx | pdf

Overview

Background
General Information
Utilization Data
Unit Prices


Sheet 1: Background

Background

Legislative Mandate for Data Request

Section 6001 (f) of the Deficit Reduction Act (DRA) requires CMS to contract with a vendor to conduct a monthly national survey of retail prescription drug prices and to report the prices to the States. These national average prices will be used as a benchmark by the States for the management of their prescription drug programs.

The law requires that the States submit pricing information for the 50 most prescribed drugs so that the States' prices can be compared to the national average prices obtained from the survey. The States' pricing information will be compared and the States will be ranked. The law also requires that States report their drug utilization rates for non-innovator multiple-source (generic) drugs, their payment rates under their State plan, and their dispensing fees.

This template has been developed to facilitate data collection from the States.

This Excel spreadsheet contains four (4) tabs: Background, General Information, Utilization Data, and Unit Prices. The first tab (this tab) provides the legislative background and mandate and requires no input from the States. The remaining tabs each have instructions for filling in the requested information.






According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average (15 hours) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850

Sheet 2: General Information




















































































































State Pricing Source Formula Dispensing Fee Schedule Reference Price Source



Pricing Compendia Other Pricing Source Pricing Source Not Listed









Sheet 3: Utilization Data









Single-Source Totals (S) Non-Innovator Multi-Source Totals (N) Innovator Multi-Source Totals (I)
Number of Prescriptions Reimbursement Amount Number of Prescriptions Reimbursement Amount Number of Prescriptions Reimbursement Amount








Sheet 4: Unit Prices


Rank NDC11 Name Strength MMIS Pricing Unit EAC Unit Price EAC Pricing Source Dispensing Fee

AWP WAC AMP RPS OTHER
1 00300304613 PREVACID 30MG

0 0 0 0 0

2 00186504031 NEXIUM 40MG


0 0 0


3 00006011731 SINGULAIR 10MG


0 0 0 0

4 00173069600 ADVAIR DISKUS 250-50MCG

0

0


5 00006027531 SINGULAIR 5MG




0


6 00310027210 SEROQUEL 200MG




0


7 50458030006 RISPERDAL 1MG




0


8 00310027110 SEROQUEL 100MG




0


9 00006071131 SINGULAIR 4MG




0


10 00071015623 LIPITOR 20MG




0


11 00456202001 LEXAPRO 20MG




0


12 00088222033 LANTUS 1000U/10ML




0


13 50458032006 RISPERDAL 2MG




0


14 00310027460 SEROQUEL 300MG




0


15 00456201001 LEXAPRO 10MG




0


16 50458030206 RISPERDAL 0.5MG




0


17 00024542131 AMBIEN 10MG




0


18 00310027510 SEROQUEL 25MG




0


19 00071015523 LIPITOR 10MG




0


20 00173069500 ADVAIR DISKUS 100-50MCG




0


21 59148000813 ABILIFY 10MG




0


22 59148000713 ABILIFY 5MG




0


23 00173064255 LAMICTAL 100MG




0


24 00069154068 NORVASC 10MG




0


25 00008084181 PROTONIX 40MG




0


26 00045064165 TOPAMAX 100MG




0


27 50458033006 RISPERDAL 3MG




0


28 00002411730 ZYPREXA 10MG




0


29 00002323730 CYMBALTA 60MG




0


30 00173069700 ADVAIR DISKUS 500-50MCG




0


31 59148000913 ABILIFY 15MG




0


32 00071015723 LIPITOR 40MG




0


33 00002442030 ZYPREXA 20MG




0


34 00069553047 ZYRTEC 5MG/5ML




0


35 00024552131 AMBIEN CR 12.5MG




0


36 00069153068 NORVASC 5MG




0


37 00069073166 ZYRTEC 10MG




0


38 00049399060 GEODON 80MG




0


39 61958070101 TRUVADA 200-300MG




0


40 00006003144 FOSAMAX 70MG




0


41 00062192015 ORTHO EVRA 3 20-150MCG/24HR




0


42 00078033705 TRILEPTAL 300MG




0


43 00597007537 SPIRIVA HANDIHALER 18MCG




0


44 00002441530 ZYPREXA 15MG




0


45 59148001013 ABILIFY 20MG




0


46 00029315920 AVANDIA 4MG




0


47 59148001113 ABILIFY 30MG




0


48 64764030114 ACTOS 30MG

0

0


49 50474059540 KEPPRA 500MG




0


50 00045152550 LEVAQUIN 500MG




0



File Typeapplication/vnd.ms-excel
Authorbbrodsky
Last Modified ByLMF
File Modified2011-09-27
File Created2007-05-02

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