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:

FDA
Product
Name

Unit
Rebate
Amount

Zip: ______

Record
ID

Units
Reimbursed

Rebate
Amount
Claimed

Number of
Prescriptions

Medicaid
Amount
Reimbursed

NonMedicaid
Amount
Reimbursed

Total
Amount
Reimbursed

TOTALS:

*Please remit this amount to:
Address:
Attn:

(Medicaid Agency)

CMS-R-144 (Exp. 07/31/2020)
OMB No. 0938-0582
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.
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.

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