Form 368 - Track Changes

MEDICAID 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 EMAIL ADDRESS

TEL: AREA PHONE NUMBER 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 EMAIL ADDRESS

TEL: AREA PHONE NUMBER 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 EMAIL ADDRESS

TEL: AREA PHONE NUMBER EXT. FAX: AREA PHONE NUMBER EXT.

NAME OF FISCAL AGENT (if applicable)

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 EMAIL ADDRESS

TEL: AREA PHONE NUMBER 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 EMAIL ADDRESS

TEL: AREA PHONE NUMBER 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. 2/2019

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.