Quarterly Utilization Report (CMS-R-144)

MEDICAID DRUG REBATE PROGRAM
STATE INVOICE RECORD FORMAT
(Form CMS-R-144)
Effective: December 1, 2011

Source: State Agencies
Target: CMS & Manufacturers
Field

Size

Position

Remarks

*Record ID

4

1–4

Constant of “FFSU” or
“MCOU”

State Code

2

5–6

P.O. Abbreviation

Labeler Code

5

7 – 11

NDC 1

Product Code

4

12 – 15

NDC 2

Package Size Code

2

16 – 17

NDC 3

Period Covered

5

18 – 22

QYYYY

Product FDA Reg. Name

10

23 – 32

Unit Rebate Amount

12

33 – 44

Product name as appears on
FDA listing form.
(1st 10 characters)
9(5).9(6)

Units Reimbursed

15

45 – 59

9(11).999

Rebate Amount Claimed

12

60 – 71

9(9).99

Number of Prescriptions

8

72 – 79

9(8)

M’Caid Amount Reimb.

13

80 – 92

9(10).99

Non-M’Caid Amount Reimb.

13

93 - 105

9(10).99

Total Amt Reimbursed

14

106 – 119

9(11).99

*Filler

1

120 – 120

All fields with decimals now require actual decimal
* Change to field