Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
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.
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.
Should you notice apparent discrepancies in an individual state's utilization data, your questions should be directed to the State Technical Contact.
The Centers for Medicare & Medicaid (CMS) posts updated State Drug Utilization Data (SDUD) according to the following schedule:
- 1st Quarter (plus 5 preceding years of data): Available in August, and includes any late data reporting for 1st Quarter received from States through the end of June, plus any updates to the five preceding years of data.
- 2nd Quarter (plus 5 preceding years of data): Available in November, and includes any late data reporting for 2nd Quarter received from States through the end of September, plus any updates to the 5 preceding years of data.
- *3rd Quarter (update of all preceding years): Available in February, and includes any late data reporting for 3rd Quarter received from States through the end of December, plus any updates to the five preceding years of data.
- 4th Quarter (plus 5 preceding years of data): Available in May, and includes any late data reporting for 4th Quarter received from States through the end of March, plus any updates to the five preceding years of data.
*An update of all preceding years of State Drug Utilization Data (1991 to 3rd Quarter) are posted to the website annually during the month of February. The data posted includes utilization information received from States through the end of December. The National Totals represent aggregate data by NDC-11.
See Also: With regards to State Drug Utilization Data (SDUD), is the data for each quarter's posting always comprehensive?
As CMS is obligated by the Federal Privacy Act, 5 U.S.C. Section 552a and the HIPAA Privacy Rule, 45 C.F.R Parts 160 and 164, to protect the privacy of individual beneficiaries and other persons, all direct identifiers have been removed and data that are less than eleven (11) counts are suppressed. An asterisk (*) notes suppressed data. CMS applies counter or secondary suppression in cases where only one prescription is suppressed for primary reasons, e.g. one prescription in a state. Also, if one sub-group (e.g. number of prescription) is suppressed, then the other sub-group is suppressed.
See Also:
No. In accordance with federal laws, State Drug Utilization Data (SDUD) that has been suppressed is not available for public consumption. As CMS is obligated by the Federal Privacy Act, 5 U.S.C. Section 552a and the HIPAA Privacy Rule, 45 C.F.R Parts 160 and 164, to protect the privacy of individual beneficiaries and other persons, all direct identifiers have been removed and data that are less than eleven (11) counts are suppressed. A checkmark in the "Suppression Used" column notes suppressed data. CMS applies counter or secondary suppression in cases where only one prescription is suppressed for primary reasons, (e.g., one prescription in a state). Also, if one sub-group (e.g., number of prescriptions) is suppressed, then the other sub-group is suppressed.