State Invoice: Crosswalk

3/2019 (old version)

12/2019 (new version)

Drug Name

FDA Product Name

Type of
Change

Reason for Change

Burden Change

Rev

To align verbiage with other Medicaid Drug
Rebate Program documentation.

N/A

No. of Scripts

Number of Prescriptions

Rev

To align verbiage with other Medicaid Drug
Rebate Program documentation.

N/A

Correction Flag

Filler

Rev

To align verbiage with other Medicaid Drug
Rebate Program documentation.

N/A

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 09380582. 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.

Form CMS-R-144 is required from States quarterly to
report utilization for any drugs paid for during that
quarter. The use of Form CMS-144 by States is
considered mandatory under the authority of Section
1927 of the Social Security Act. Under the Privacy Act
of 1974 any personally identifying information obtained
will be kept private to the extent of the law.

Rev

To conform to new disclosure statement rules

N/A

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 0938-0582. 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.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesgnation.