Medicaid Drug Rebate Program - Manufacturers and Supporting Regulation at 42 CFR 447.534 (CMS-367)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0578 can be found here:

Documents and Forms

Document Name Document Type
CMS-367 -Disclosure Statement -CLEAN 3.25.16.docx Other-PRA Disclosure Statement
CMS-367 - Instructions to Labelers -CLEAN - updated.3 25 16.docx Instruction
CORRECTION PRA Disclosure Statement for CMS-367a b and c.docx Other-Correction to PRA Disclosure S
CMS-367a, CMS-367b Medicaid Drug Program Monthly and Quarterly Drug Reporti DDR Screenshots for CMS-367a_b_c_3.18.16.docx Form
CMS-367d Supplemental Data Sheet Form367(d)updated.pdf Form
Form Record Specification Crosswalk - 3 16 16.xlsx Crosswalk - Record Specification IC Document
Instructions for Labelers Crosswalk 3 16 16.xlsx Crosswalk - Instructions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicaid Drug Rebate Program - Manufacturers and Supporting Regulation at 42 CFR 447.534 (CMS-367)	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
Other-Correction to PRA Disclosure Statement			CORRECTION PRA Disclosure Statement for CMS-367a b and c.docx	No		Printable Only
Form	CMS-367a, CMS-367b, and CMS-367c	Medicaid Drug Program Monthly and Quarterly Drug Reporting	DDR Screenshots for CMS-367a_b_c_3.18.16.docx	Yes	Yes	Fillable Printable
Instruction			CMS-367 - Instructions to Labelers -CLEAN - updated.3 25 16.docx	Yes	No	Printable Only
Other-PRA Disclosure Statement			CMS-367 -Disclosure Statement -CLEAN 3.25.16.docx	No		Printable Only
Form	CMS-367d	Supplemental Data Sheet	Form367(d)updated.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 610	Number of Respondents for Small Entity: 100

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	12,810	2,440	10,370
Annual IC Time Burden (Hours)	3,612,603	3,456,260	156,343
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk - Record Specification	Form Record Specification Crosswalk - 3 16 16.xlsx	03/18/2016
Crosswalk - Instructions	Instructions for Labelers Crosswalk 3 16 16.xlsx	03/18/2016

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