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pdfMEDICAID DRUG REBATE PROGRAM (MDRP)
and DRUG UTILIZATION REVIEW (DUR) PROGRAM
STATE AGENCY CONTACT FORM
STATE AGENCY NAME
MDRP STATE DDR CONTACT – Provide official state email address.
NAME OF CONTACT
TEL: AREA PHONE NUMBER
EMAIL ADDRESS
EXT.
FAX: AREA PHONE NUMBER
EXT.
STREET ADDRESS
CITY
STATE
ZIP CODE
MDRP TECHNICAL CONTACT – Person responsible for sending and receiving data.
NAME OF CONTACT
TEL: AREA PHONE NUMBER
EMAIL ADDRESS
EXT.
FAX: AREA PHONE NUMBER
EXT.
NAME OF FISCAL AGENT (if applicable)
STREET ADDRESS
CITY
STATE
ZIP CODE
MDRP POLICY CONTACT – Person responsible for policy decisions.
NAME OF CONTACT
TEL: AREA PHONE NUMBER
EMAIL ADDRESS
EXT.
FAX: AREA PHONE NUMBER
EXT.
NAME OF FISCAL AGENT (if applicable)
CMS-368 (Exp. 07/31/2020) / OMB No. 0938-0582 / Rev. 3/2019
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0582. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing
data sources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
MEDICAID DRUG REBATE PROGRAM (MDRP)
and DRUG UTILIZATION REVIEW (DUR) PROGRAM
STATE AGENCY CONTACT FORM
STATE AGENCY NAME
MDRP POLICY CONTACT – Continued
STREET ADDRESS
CITY
STATE
ZIP CODE
MDRP REBATE CONTACT – Person responsible for invoice and receipt of rebate payments.
NAME OF CONTACT
TEL: AREA PHONE NUMBER
EMAIL ADDRESS
EXT.
FAX: AREA PHONE NUMBER
EXT.
NAME OF FISCAL AGENT (if applicable)
STREET ADDRESS
CITY
STATE
ZIP CODE
DUR STATE CONTACT – Person responsible for state DUR. Must have a valid state email address.
NAME OF CONTACT
TEL: AREA PHONE NUMBER
EMAIL ADDRESS
EXT.
FAX: AREA PHONE NUMBER
EXT.
NAME OF FISCAL AGENT (if applicable)
STREET ADDRESS
CITY
STATE
ZIP CODE
CMS-368 (Exp. 07/31/2020) / OMB No. 0938-0582 / Rev. 3/2019
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0582. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing
data sources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
| File Type | application/pdf |
| Author | ANDREA WELLINGTON |
| File Modified | 2019-03-01 |
| File Created | 2019-03-01 |