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Tab: Data Elements
Cell A2
Product FDA List Name
Tab: Data Elements
Cell A3
NDC
2024 (new version)
Tab: Data Elements
Cell A2
Tab: Data Elements
Cell A3
Burden Change
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Product FDA List Name
Tab: Data Elements
Cell A4
# of Prescriptions
NDC
Cost to the State to Administer VBP
(Estimated to the nearest dollar. States may
approximate the amount of administrative
costs for a single administrative contract used
for multiple arrangements.)
Reason for Change
Calendar Year
Tab: Data Elements
Cell A4
Tab: Data Elements
Cell A5
Type of Change
Tab: Data Elements
Cell A5
# of Prescriptions (number of
beneficiaries)
Tab: Data Elements
Cell A6
Total Savings generated by the supplemental
rebate due to VBP (Estimated to the nearest
dollar)
Tab: Data Elements
Cell A7
Annual report due
Tab: Data Elements
Cell A8
BLANK CELL
Tab: Data Elements
Cell A9
BLANK CELL
Tab: Data Elements
Cell A6
Cost to the State to Administer
VBP (Estimated to the nearest
dollar. States may approximate
the amount of administrative
costs for a single administrative
contract used for multiple
arrangements.)
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Tab: Data Elements
Cell A7
Total Revenue received by
supplemental rebate under VBP
by end of calendar year
Tab: Data Elements
Cell A8
Total Savings generated by the
supplemental rebate due to VBP
(Estimated to the nearest dollar)
Tab: Data Elements
Cell A9
Annual report due
Tab: Data Elements
Cell B2
Tab: Data Elements
Cell B2
For each VBP arrangement.
Enter the calendar year in the following
format: i.e. "2023", "2024"
Tab: Data Elements
Cell B3
Tab: Data Elements
Cell B3
NDC 9s used in arrangement (at dosage form and
strength level). Example: 00001-1234, 1244, 1254,
For each VBP arrangement which the
State received manufacturer rebates in
the prior CY.
Tab: Data Elements
Cell B4
Tab: Data Elements
Cell B4
The # of prescriptions should reflect the # of Medicaid
beneficiaries receiving the prescribed treatment whether
single or multiple doses under the state's VBP for the NDC
9s listed. State should reflect # of beneficiaries receiving
treatment over the year.
NDC 9s used in arrangement (at dosage
form and strength level). Example:
00001-1234, 1244, 1254,
Tab: Data Elements
Cell B5
Tab: Data Elements
Cell B5
Calculated as the estimated administrative costs to the
state to enter into and administer each VBP arrangement.
Examples of administrative costs states may incur: The
costs applicable to negotiating the contract, the
applicable cost of collecting data, the applicable cost of a
contract with a fiscal agent to develop, invoice and collect
rebates, applicable costs to entities collecting and
verification of patient or population data, state cost of
filling out this survey. *We understand that there may be
start-up costs only reflected in the first year.
The # of prescriptions (number of
beneficiaries) field should reflect the # of
Medicaid beneficiaries receiving the
prescribed treatment whether single or
multiple doses under the state's VBP for
the NDC 9s listed. State should reflect #
of beneficiaries receiving treatment over
the year because the outcome and the
rebate the state receives is based on a
single beneficiary’s outcome and not the
outcome of a single prescription.
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Tab: Data Elements
Cell B6
Tab: Data Elements
Cell B6
Calculated as the Supplemental rebate collected minus
the Costs to state to administer VBP
Calculated as the estimated
administrative costs to the state to enter
into and administer each VBP
arrangement. Examples of administrative
costs states may incur: The costs
applicable to negotiating the contract,
the applicable cost of collecting data, the
applicable cost of a contract with a fiscal
agent to develop, invoice and collect
rebates, applicable costs to entities
collecting and verification of patient or
population data, state cost of filling out
this survey. For reporting purposes states
can consolidate its administrative, and if
applicable, clinical costs associated with
the VBP arrangement.
States do not need to determine the
precise cost of administering each
contract and may estimate the
percentage of time its state employees
dedicated to VBP arrangements in
comparison to the rest of their duties for
this data element. Approximating % of
FTE salary dedicated to VBP contracts/#
VBP arrangements the state employee
oversees would be appropriate. For
example - employee’s annual salary is
$60,000 and spends 10% of their time on
VBP arrangement negotiation and
administration. The state has 6 VBP
contracts the employee sees. Therefore,
for each VBP contract the state has
estimated a $1000 cost associated with
operating the contract.
*We understand that there may be startup costs only reflected in the first year.
Redesignation
Formatting and
Clarification edit
No
Tab: Data Elements
Cell B7
Tab: Data Elements
Cell B7
The period for the VBP reporting will be on CY.
Therefore, the first period will include VBP arrangements
in effect during CY 2022 (1/1/2022 through 12/31/22).
The submission of reports for the CY 22 will take place 60
days after the end of CY or March 1, 2023.
This should field should only include
rebate revenue generated by the VBP
arrangement.
Tab: Data Elements
Cell B8
Tab: Data Elements
Cell B8
BLANK CELL
This field is populated via formula.
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Tab: Data Elements
Cell B9
Tab: Data Elements
Cell B9
BLANK CELL
The period for the VBP reporting will be
on CY. Therefore, the first reporting
period will include VBP arrangements in
effect during CY 2022 (1/1/2022 through
12/31/22). The submission of reports for
the CY 22 will take place 60 days after
the end of CY or March 1, 2023. If the
state needs to update the report with
additional (lagged) information after the
60 day cut off, the state may resubmit
the report with the updated information.
Tab: State Summary
Cell A1
Tab: State Summary
Cell A1
Product FDA List Name
Calendar Year
Tab: State Summary
Cell B1
Tab: State Summary
Cell B1
NDC for drugs covered by VBP
Product FDA List Name
Tab: State Summary
Cell C1
Tab: State Summary
Cell C1
Number of Prescriptions
NDC for drugs covered by VBP
Tab: State Summary
Cell D1
Tab: State Summary
Cell D1
Cost to State to Administer VBP (need
standard computation)
Number of Prescriptions (number
of beneficiaries)
Tab: State Summary
Cell E1
Tab: State Summary
Cell E1
Total Savings generated by supplemental
rebate under VBP
Cost to State to Administer VBP
(need standard computation)
Tab: State Summary
Cell F1
BLANK CELL
Tab: State Summary
Cell G1
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Tab: State Summary
Cell F1
Total Revenue received by
supplemental rebate under VBP
by end of calendar year
Tab: State Summary
Cell G1
BLANK CELL
Total Savings generated by
supplemental rebate under VBP
Tab: State Summary
Cell H1
Tab: State Summary
Cell H1
BLANK CELL
Notes
Tab: State Summary
Cell A2
Tab: State Summary
Cell A2
Year 1 (10/1/2021 - 9/30/2022)
2023
Tab: State Summary
Cell B2
Tab: State Summary
Cell B2
BLANK
Drug A Name
Tab: State Summary
Cell C2
Tab: State Summary
Cell C2
BLANK
NDC - 1, NDC - 2, NDC - 3,
NDC - 4
Tab: State Summary
Cell D2
Tab: State Summary
Cell D2
BLANK
250
Tab: State Summary
Cell E2
Tab: State Summary
Cell E2
BLANK
$75,000
Tab: State Summary
Cell F2
Tab: State Summary
Cell F2
BLANK
$225,000
Tab: State Summary
Cell G2
Tab: State Summary
Cell G2
BLANK
$150,000
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Tab: State Summary
Cell A3
Drug A Name
Tab: State Summary
Cell B3
NDC - 1, NDC - 2, NDC - 3, NDC - 4
Tab: State Summary
Cell C3
250
Tab: State Summary
Cell D3
$75,000
Tab: State Summary
Cell E3
$225,000
Tab: State Summary
Cell F3
BLANK
Tab: State Summary
Cell G3
BLANK
Tab: State Summary
Cell A3
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
2024
Tab: State Summary
Cell B3
Drug B Name
Tab: State Summary
Cell C3
NDC - 1, NDC - 2
Tab: State Summary
Cell D3
100
Tab: State Summary
Cell E3
$50,000
Tab: State Summary
Cell F3
$350,000
Tab: State Summary
Cell G3
$300,000
Tab: State Summary
Cell A4
Tab: State Summary
Cell A4
Drug B Name
2023
Tab: State Summary
Cell B4
Tab: State Summary
Cell B4
NDC - 1, NDC - 2
Drug A Name
Tab: State Summary
Cell C4
Tab: State Summary
Cell C4
100
NDC - 1, NDC - 2, NDC - 3,
NDC - 4
Tab: State Summary
Cell D4
Tab: State Summary
Cell D4
$50,000
400
Tab: State Summary
Cell E4
Tab: State Summary
Cell E4
$350,000
$75,000
Tab: State Summary
Cell F4
Tab: State Summary
Cell F4
BLANK
$225,000
Tab: State Summary
Cell G4
Tab: State Summary
Cell G4
BLANK
$150,000
Tab: State Summary
Cell A5
Tab: State Summary
Cell A5
Year 1 (10/1/2021 - 9/30/2022)
2024
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Tab: State Summary
Cell B5
Tab: State Summary
Cell B5
BLANK
Drug B Name
Tab: State Summary
Cell C5
This cell includes the following formula:
=sum(C3:C4)
Tab: State Summary
Cell D5
This cell includes the following formula:
=sum(D3:D4)
Tab: State Summary
Cell E5
Tab: State Summary
Cell C5
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Redesignation
Formatting and
Clarification edit
No
Deletion
Formatting and
Clarification edit
No
NDC - 1, NDC - 2
Tab: State Summary
Cell D5
50
Tab: State Summary
Cell E5
This cell includes the following formula:
=sum(E3:E4)
$50,000
Tab: State Summary
Cell F5
Tab: State Summary
Cell F5
Year 1 total for all
$350,000
Tab: State Summary
Cell G5
Tab: State Summary
Cell G5
BLANK
$300,000
Tab: State Summary
ROWS 6-15 Included Data
Redesignation
Tab: State Summary
ROWS 6-15 are BLANK
Type of Change: Rev = Revision, Del = Dele�on, Add = Addi�on, and Red = Redesigna�on.
The below is a summary of the edits made to the original -State Summary tab:
1. Ensured all cells are not merged.
2. The “year” is no longer a row, but a column.
3. Removed total and cumulative rows.
4. Updated "Year" column header to "Calendar Year"
5. Updated "Number of Prescriptions" column header to "Number of Prescriptions (number of beneficiaries)"
6. Added "Total Revenue received by supplemental rebate under VBP by end of calendar year" column
7. Added formula within the Total Savings generated by supplemental rebate under VBP
Note: Yellow highlighted indicate that edits have been made, as described above.
Calendar Year
Product FDA List
Name
NDC for drugs
covered by VBP
Number of
Prescriptions
(number of
beneficiaries)
Cost to State to
Administer VBP
(need standard
computation)
Total Revenue
received by
supplemental rebate
under VBP
by end of calendar
year
Total Savings
generated by
supplemental rebate
under VBP
2023
Drug A Name
NDC - 1, NDC - 2, NDC
- 3, NDC - 4
250
$
75,000
$
225,000
$
150,000
2024
Drug B Name
NDC - 1, NDC - 2
100
2023
Drug A Name
NDC - 1, NDC - 2, NDC
- 3, NDC - 4
400
$
50,000
$
75,000
$
350,000
$
225,000
$
300,000
$
150,000
2024
Drug B Name
NDC - 1, NDC - 2
$
50,000
$
350,000
$
300,000
50
Notes
| File Type | application/pdf |
| Author | Weinschneider, Abraham (CMS/CMCS) |
| File Modified | 2024-02-09 |
| File Created | 2024-02-09 |