MEDICAL EXPENDITURE PANEL SURVEY

MEDICAL PROVIDER COMPONENT

DATA FORM FOR PHARMACIES

FOR

REFERENCE YEAR 2009

Q1.  Date Filled:                        MONTH___ DAY ___ 2009

Q2.  Prescription information will be identified using:   

      NDC                          (GO TO Q2a)

      Drug Name, Strength/Unit, and Dosage Form (GO TO Q2b)

      Q2a.  NDC:  _____-____-__ (GO TO Q3a/b)

            IF DRUG IS A COMPOUND ENTER 99999-9999-96

      Q2b. Drug Name: ____                      

      Q2c/d. Strength/Unit.  Strength:___   Unit:___  

      Q2e.  Dosage Form:___    

            IF ITEM IS A PRODUCT RECORD THE ITEM NAME AS THE DOSAGE FORM (E.G., IF PROFILE SAYS BACK BRACE,DOSAGE FORM SHOULD BE BRACE).

            DO NOT RECORD CONTAINERS VIALS, BOTTLES, TUBES, ETC.) OR EACH (EA) AS DOSAGE FORMS.

Q3a/b.      Quantity/Unit. Quantity:___     Unit: ___  

            NOTE 1: QUANTITY MUST BE THE CONTENTS OF A CONTAINER, NOT THE NUMBER OF CONTAINERS. EXCEPTION: IF AN NDC IS GIVEN THE   QUANTITY OF AN EPIPEN MAY BE ACCEPTED AS THE NUMBER OF EPIPENS (VERSUS THE QUANTITY OF THE CONTENTS OF THE EPIPEN).

      NOTE 2: ACCEPT A QUANTITY OF 1 OR 2 FOR A DEVICE.

      NOTE 3: ACCEPT A QUANTITY OF 1 OR 2 FOR PILLS, UNLESS IT LOOKS LIKE THE QUANTITY IS FOR ONE OR TWO DOSEPAKS, WHICH MAY CONTAIN MULTIPLE PILLS (THEN NEED TO ASK FOR THE QUANTITY OF TABLETS, CAPSULES, ETC. THAT THE DOSEPAK CONTAINS).

      NOTE 4: FOR OINTMENTS, CREAMS, DROPS, LIQUID, FILLED SYRINGES (EXCEPT EPIPENS) AND OTHER DOSAGE FORMS THAT NEED A QUANTITY UNIT, ASK FOR THE QUANTITY OF THE CONTENTS.

Q4.   Patient Payment: $___.__ (ALLOW AMOUNTS FROM $0 TO 500.)

Q5.   Type of 3rd Party Payer: ______              

      NONE ___

      IF PATIENT PAYMENT WAS $1 OR LESS,EXPECT THE 3rd PARTY PAYER TO BE A PUBLIC PROGRAM, E.G., MEDICAID OR OTHER STATE/LOCAL GOVT, ETC.

Q6.   3rd Party Payment:$___.__   (ALLOW AMOUNTS FROM $0 TO $5,000.)

___ CHECK HERE FOR NEXT PRESCRIPTION

[WHEN THIS BOX IS CHECKED, THE SAME QUESTIONS FOR A NEW PRESCRIPTION WILL BE

AUTOMATICALLY GENERATED BY THE SYSTEM]