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:

(Medicaid Agency)

CMS-R-144 (Exp. TBD)
OMB No. 0938-0582
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 v alid OMB control number for this information
collection is 0938-0582. The time required to complete this information collection is estimated to average 46 hours per response, including the time to review instructions, search existing data sources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate 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.