Form CMS-376a Quarterly Pricing Data

Online Quarterly Pricing Data Entry Screen in MDP (CMS-367a)

Form CMS-367a (Exp. 02/28/2023) is used by manufacturers on a quarterly basis, to transmit pricing data for each of their covered outpatient drugs to CMS either electronically or via file
transfer. The use of Form CMS-367a on a quarterly basis by manufacturers is considered mandatory under the authority of Section 1927 of the Social Security Act and the National Drug Rebate
Agreement. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 0938-0578. The
time required to complete this information collection is estimated to average 34.8 hours per response, including the time to review instructions, 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, Baltimore, Maryland 21244-1850.