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
"Units Reimbursed" are the number of units (based on Unit Type) of the drug (11-digit NDC level) reimbursed by the state or, for MCO drugs, the number of units dispensed during the Quarter/Year. For more specific information, you may contact either the Drug Manufacturer or State via the contact lists.
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.
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.