Administrative Data Report (CMS-368)

Medicaid Drug Rebate Program Forms (CMS-368 and CMS-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⚠️ Notice: This information collection may be referencing outdated material.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 Administrative Data Report (CMS-368) Form
CMS-368 Medicaid Drug Rebate Program, State Agency Contact Form CMS-368 with Disclosure Statement_Updated-Final_03.01.2019.pdf Form
CMS-368 Record SpecificationCrosswalk_2019.xlsx Crosswalk IC Document
CMS-368 with Disclosure Statement_TC_03.01.2019.docx Form 368 - Track Changes IC Document

Information Collection (IC) Details

IC Title:	Administrative Data Report (CMS-368)	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-368	Medicaid Drug Rebate Program, State Agency Contact Form	CMS-368 with Disclosure Statement_Updated-Final_03.01.2019.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	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	10	10
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	CMS-368 Record SpecificationCrosswalk_2019.xlsx	01/25/2019
Form 368 - Track Changes	CMS-368 with Disclosure Statement_TC_03.01.2019.docx	03/01/2019

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