State Drug Rebate (Medicaid)

State Drug Rebate (Medicaid) (CMS-368 and R-144)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0582 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-368 State Drug Rebate (Medicaid) Form
Invoice Instructions.doc Instruction
CMS-368 State Contact Agency Form CMS-368 statecontactform.pdf Form
CMS-R-144 Medicaid Drug Rebate Invoice CMS R-144.pdf Form
Data Definitions.doc Data Definitions IC Document
Record Layout.doc Record Layout IC Document

Information Collection (IC) Details

IC Title:	State Drug Rebate (Medicaid)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-368	State Contact Agency Form	CMS-368 statecontactform.pdf	Yes	Yes	Fillable Fileable
Form	CMS-R-144	Medicaid Drug Rebate Invoice	CMS R-144.pdf	Yes	Yes	Fillable Fileable
Instruction			Invoice Instructions.doc	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	204	204
Annual IC Time Burden (Hours)	9,389	9,389
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Data Definitions	Data Definitions.doc	03/06/2009
Record Layout	Record Layout.doc	03/06/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.