CMS-367a, -367b, - Medicaid Drug Program Monthly and Quarterly Drug Reporti

CMS RECORD SPECIFICATION
DDR QUARTERLY PRICING DATA
TEXT FILE FOR TRANSFER TO CMS
Source: Drug Manufacturers
Target: CMS
Field

Size

Position

Record ID

1

1-1

Constant of “Q”

Labeler Code

5

2-6

NDC #1

Product Code

4

7 - 10

NDC #2

Package Size

2

11 – 12

NDC #3

Period Covered

5

13 – 17

QYYYY (Qtr/Yr)

Average Mfr Price

12

18 – 29

99999.999999

Best Price

12
9
9

30 – 41
42 – 50
51 – 59

99999.999999
999999999
999999999

Nominal Price
Customary Prompt Pay Disc.
CMS-367a (Exp. )
OMB No. 0938-0578

Remarks

CMS RECORD SPECIFICATION
DDR MONTHLY PRICING DATA
TEXT FILE FOR TRANSFER TO CMS
Source: Drug Manufacturers
Target: CMS
Field

Size

Position

Record ID

1

1–1

Constant of “M”

Labeler Code

5

2–6

NDC #1

Product Code

4

7 – 10

NDC #2

Package Size

2

11 – 12

NDC #3

Month

2

13 – 14

MM

Year

4

15 – 18

YYYY

Average Mfr Price

12

19 – 30

99999.999999

AMP Units

14

31 – 44

99999999999.99

Filler

6

45 – 50

spaces

CMS-367b (Exp. )
OMB No. 0938-0578

Remarks

CMS RECORD SPECIFICATION
DDR DRUG PRODUCT DATA
TEXT FILE FOR TRANFER TO CMS
Source: Drug Manufacturers
Target: CMS
Field

Size

Position

Record ID

1

1–1

Constant of “P”

Labeler Code

5

2–6

NDC #1

Product Code

4

7 – 10

NDC #2

Package Size Code

2

11 - 12

NDC #3

Drug Category

1

13 - 13

See Data Element Definitions

Unit Type

3

14 - 16

See Data Element Definitions

FDA Approval Date

8

17 - 24

MMDDYYYY

FDA Thera. Eq. Code

2

25 - 26

See Data Element Definitions

Market Date

8

27 - 34

MMDDYYYY

Termination Date

8

35 - 42

MMDDYYYY

DESI Indicator

1

43 - 43

See Data Element Definitions

Drug Type Indicator

1

44 - 44

See Data Element Definitions

OBRA’90 Baseline AMP

12

45 - 56

99999.999999

Units Per Pkg Size

11

57 - 67

9999999.999

FDA Product Name

63

68 - 130

FDA Product Name

DRA Baseline AMP

12

131 – 142

99999.999999

Package Size Intro Date

8

143 – 150

MMDDYYYY

Purchased Product Date

8

151 – 158

MMDDYYYY

CMS-367c (Exp. )
OMB No. 0938-0578

Remarks

MEDICAID DRUG REBATE AGREEMENT
ENCLOSURE B (PAGE 1 OF 2)
SUPPLEMENTAL DATA SHEET

LABELER CODE (as assigned by FDA)

LABELER NAME (Corporate name associated with labeler code)

LEGAL CONTACT – Person to contact for legal issues concerning the rebate agreement

NAME OF CONTACT
AREA

PHONE NUMBER

EXTENSION

NAME OF CORPORATION

STREET ADDRESS

CITY

STATE

ZIP CODE

INVOICE CONTACT – Person responsible for processing invoice utilization data

NAME OF CONTACT
AREA

PHONE NUMBER

EXTENSION

NAME OF CORPORATION

STREET ADDRESS

CITY

STATE

ZIP CODE

Note: This sheet is to be returned with the signed rebate agreement. If more than one labeler code,
attach one sheet for each code.
CMS-367d (Exp. )
OMB No. 0938-0578

MEDICAID DRUG REBATE AGREEMENT
ENCLOSURE B (PAGE 2 OF 2)
SUPPLEMENTAL DATA SHEET
LABELER CODE (as assigned by FDA)

LABELER NAME (Corporate name associated with labeler code)

TECHNICAL CONTACT – Person responsible for sending and receiving data

NAME OF CONTACT
AREA

PHONE NUMBER

EXTENSION

FAX #
______________________________
EMAIL Address:
______________________________
NAME OF CORPORATION

STREET ADDRESS

CITY

STATE

ZIP CODE

Note: This sheet is to be returned with the signed rebate agreement. If more than one labeler code,
attach one sheet for each code.
CMS-367d (Exp. )
OMB No. 0938-0578