Frequently Asked Questions

A Non-Medicaid Reimbursed amount is any amount paid on a claim by parties other than Medicaid (e.g., other federal coverage, co-pay, private insurance). If a state receives Federal Financial Participation (FFP) for any part of a claim for a Covered Outpatient Drug (COD), that portion of the claim is included in the Medicaid Reimbursed amount. If a state does not receive FFP for any part of a rebate-eligible claim, then the amount of the claim is included in the Non-Medicaid Reimbursed amount.

The sum of the “Medicaid Amount Reimbursed” and the “Non-Medicaid Amount Reimbursed” fields should generally equal the Total Amount Reimbursed on a National Drug Code (NDC) by NDC basis; however, these new fields were implemented beginning with the fourth quarter of 2007 and are optional for the states to report prior to that time. Therefore, for quarters earlier than fourth quarter 2007, there may be some large discrepancies between the Total Amount Reimbursed and the sum of the Medicaid Amount Reimbursed and the Non-Medicaid Amount Reimbursed because the Non-Medicaid Amount Reimbursed is often not present for those earlier quarters. Should you notice apparent discrepancies in an individual state's utilization data, your questions should be directed to the State Technical Contact.

Amounts reimbursed by Medicaid are pre-rebate, not net of rebates.

States are required to submit their utilization data to CMS within 60 days of the end of the rebate period.

Per section 1927 of the Act, initial submissions of quarterly state utilization data are due to CMS within 60 days of the end of each rebate period. If a state fails to report utilization data in the quarter that it was dispensed, the state must submit initial utilization data for the most recently closed quarter as well as adjustments/corrections to any previously reported utilization data.

Drug coverage under Medicaid is an optional benefit for the states. However, if a state opts to cover prescription drugs in their Medicaid program, they must participate in the MDRP.  As part of that participation in the MDRP, states are required to submit quarterly drug utilization data to CMS.  All states and the District of Columbia currently participate in the MDRP; therefore, they all submit quarterly drug utilization data to CMS.

In general, all states cover all drugs (that meet the statutory definition of a covered outpatient drug per section 1927 of the Social Security Act (the Act)) of every manufacturer that participates in the Medicaid Drug Rebate Program (MDRP). However, section 1927(d)(2) of the Act does list several categories of drugs that states may, at their option, exclude or restrict from coverage under the MDRP. These categories include things like non-prescription drugs, drugs used for cosmetic purposes, etc. Therefore, while most states cover the same subset of drugs, there is some flexibility afforded to the states which can result in coverage differences from one state to the next.

State-only program utilization (e.g. ADAP) should not be included in the Federal State Medicaid Drug Rebate Program.

Each quarter, a drug product listing is available from the  approximately 45 days after the close of the quarter. This information contains the active drugs that have been reported for inclusion in the Medicaid Drug Rebate Program (MDRP) by participating drug manufacturers as of the most recent rebate reporting period.

The drug utilization data that states report to CMS is reported at the NDC level. Therefore, for purposes of the Medicaid Drug Rebate Program (MDRP), crosswalk from HCPCS code to NDC should have already occurred prior to the states reporting their drug utilization data to CMS. Medicare Part B does post a HCPCS to NDC crosswalk ; however, please note that the subset of drugs covered under Part B is much smaller than  the drugs covered under the MDRP. Therefore, you may not find this crosswalk to be all-inclusive of every product covered under the MDRP.