Form CMS-367e Quarterly VBP-MBP Data

Mockup* for MDP Quarterly VBP-MBP Online Data Entry (CMS-367e)

Form CMS-367e (Exp. TBD) is used by manufacturers on a quarterly basis, to transmit pricing data (best prices associated with value-based purchasing (VBP) arrangements) for each of their covered
outpatient drugs to CMS either electronically or via file transfer. The use of Form CMS-367e on a quarterly basis by manufacturers is considered mandatory under the authority of Section 1927 of the
Social Security Act, 42 CFR 447.510 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 1 hour 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.

*Note: This is a mockup because this module has not yet been built in our MDP system.