Form CMS-10241 NADAC Survey Tool (English)

(ADD DATE), 2023

Dear Pharmacy Owner/Manager:

The Centers for Medicare & Medicaid Services (CMS), Center for Medicaid and CHIP Services, Division of Pharmacy has developed the National Average Drug Acquisition Cost (NADAC) benchmark as a pricing resource for state Medicaid programs. CMS has engaged Myers and Stauffer LC (Myers and Stauffer), a certified public accounting firm, to conduct a pricing survey and maintain the NADAC reference files.

This month, your pharmacy has been selected to respond. Completion of this survey is vital to the Medicaid reimbursement process for pharmacies More than 40 state Medicaid programs utilize the NADAC as a part of their reimbursement methodology, which means your participation directly impacts your reimbursement rate.

Therefore, we are requesting your pharmacy provide the following information within 10 calendar days:

Copies of all wholesaler, distributor, or manufacturer invoices, reflecting all brand, generic, and over-the-counter drug purchases transacted with all your wholesale supplier(s) and/or drug manufacturer(s) between (ADD Dates).

Please do not send any invoices that include purchases through the 340B Drug Pricing Program.

Information should be submitted in printed or electronic format and should include the following information:

1. National Drug Code (NDC).

2. Labeler Name/Product Name

3. Purchase price of drug (drug ingredient cost only).

4. Quantity purchased.

5. Purchase date for each product.

6. Wholesaler/supplier.

If the invoice provided only contains an “item number” without an NDC, please provide the item number for each purchase and an item number-to-NDC crosswalk from your wholesaler

As a time-saving alternative to you or your pharmacy staff directly submitting invoice records, you may contact your drug supplier(s) to request and authorize them to forward an electronic or hard copy of your purchasing history for the requested period (as described above) directly to Myers and Stauffer.

Information should be emailed, mailed, or faxed, to the following address within 10 calendar days:

Method	Information
Email	To: [email protected] Subject: CMS Pharmacy Survey – confidential and proprietary
Mail	Myers and Stauffer LC Attn: CMS Pharmacy Survey 800 E 96th Street, Suite 200 Indianapolis, IN 46240
Fax	(844) 860-0236 Attn: CMS Pharmacy Survey

Since submitted information will not be returned, please submit copies or electronic files of these records.

Additional information regarding the NADAC reference file and the confidentiality of submitted information are available on the CMS Medicaid website at the links provided below.

NADAC reference file: https://www.medicaid.gov/medicaid/prescription-drugs/pharmacy-pricing/index.html

Confidentiality Statement (see page 48): https://www.medicaid.gov/medicaid-chip-program-information/by-topics/prescription-drugs/ful-nadac-downloads/nadacmethodology.pdf

Please contact the NADAC Help Desk, operated by Myers and Stauffer at 855.457.5264 or [email protected] if you have any questions regarding this survey.

Thank you for your participation in this important process.

Sincerely,

Director, Medicaid Benefits and Health Programs Group
Center for Medicaid and CHIP Services

Centers for Medicare & Medicaid Services (CMS)

PRA Disclosure Statement: The purpose of the Survey of Retail Prices PRA package is to allow CMS to send a monthly, voluntary survey to retail community pharmacies in order to collect the invoices of drug ingredient costs and develop a pricing file. 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 0938-1041 (expires: XX/XX/XXXX). The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. If you have comments concerning the accuracy of the time estimate(s) 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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