Quarterly Utilization Report (CMS-R-144)

Medicaid Drug Rebate Program (MDRP): Quarterly State Invoice (CMS-R-144) and State Agency Contact Form (CMS-368)

CMS-R-144 State Invoice_Record Format_12.2019_Final

Quarterly Utilization Report (CMS-R-144)

OMB: 0938-0582

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MEDICAID DRUG REBATE PROGRAM

STATE INVOICE RECORD FORMAT

(Form CMS-R-144)

Effective: February 1, 2020


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


2


16 – 17


NDC 3


Period Covered


5


18 – 22


QYYYY


FDA Product Name


10


23 – 32


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


Unit Rebate Amount (URA)


12


33 – 44


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)

Medicaid Amount Reimbursed (MAR)


13


80 – 92


9(10).99


Non-Medicaid Amount Reimbursed (NMAR)


13


93 - 105


9(10).99


Total Amount Reimbursed (TAR)


14


106 – 119


9(11).99



Filler



1



120 – 120










All fields with decimals now require actual decimal

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleMEDICAID DRUG REBATE PROGRAM
AuthorCMS
File Modified0000-00-00
File Created2021-01-14

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