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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Medicaid Drug Rebate Program - Manufacturers and Supporting Regulation at 42 CFR 447.534
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-367a
DDR Quarterly Pricing Data
CMS-367a instrument.doc
Yes
Yes
Fillable Fileable
Form
CMS-367b
DDR Monthly Pricing Data
CMS-367b instrument.doc
Yes
Yes
Fillable Fileable
Form
CMS-367c
DDR Drug Product Data
CMS-367c instrument.doc
Yes
Yes
Fillable Fileable
Form
CMS-367d
Medicaid Drug Rebate Agreement
CMS-367d instrument.doc
Yes
Yes
Fillable Fileable
Instruction
CMS-367 Instructions to Labelers.doc
No
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
540
Number of Respondents for Small Entity:
100
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
100 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
8,640
0
6,360
0
0
2,280
Annual IC Time Burden (Hours)
106,272
0
51,492
0
0
54,780
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Relevant Statute
367Relevant Statute.doc
Disclosure Statement
CMS-367 disclosure statement.doc
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.