CMS-368 State Agency Contact Form

MEDICAID DRUG REBATE PROGRAM

STATE AGENCY CONTACT FORM

Form CMS-368

STATE AGENCY NAME

STATE MDP CONTACT – Person must have a valid state email address.

NAME OF CONTACT EMAIL ADDRESS

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

STREET ADDRESS

CITY STATE ZIP CODE

STATE 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

STATE AGENCY NAME

STATE 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)

STREET ADDRESS

CITY STATE ZIP CODE

STATE 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

CMS-368 (Exp. 06/30/2023) / OMB No. 0938-0582

Form CMS-368 is a report of contact for the State to name the individuals involved in the Medicaid Drug Rebate Program (MDRP), and is required only in those instances where a change to the originally submitted data is necessary. When needed, the use of Form CMS-368 by the State is considered mandatory under the authority of Section 1927 of the Social Security Act. 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 0938-0582. 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.