Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Preparation and Issuance of Model Notices (section 423.120(c)(6)) Unchanged 95000 7885 0
Business Continuity Plans under 422.504(o) and 423.505(p) Unchanged 99 15920 0
Creation of Model Notices (Plans) (section 423.120(c)(6)) Unchanged 212 636 0
Medicare Prescription Drug Benefit Program (Benes) Unchanged 9869100 2847975 0
Medicare Prescription Drug Benefit Program (Plans) Modified 43863133 5690947 0 Form CMS-10141 Compensation Certification
Instruction
Form CMS-10141 Description of Compensation Structure
Form CMS-10141 Covered Agent Information Sheets Workbook
Form CMS-10141 Compensation Structure for Writing Agents by Contract/PBP Number
Form CMS-10141 Initial Notice: Notice of Intent to Limit Your Access to Certain Part D Drugs
Form CMS-10141 Second Notice: Your Access to Certain Part D Drugs is Limited
Form CMS-10141 Alternate Second Notice
Instruction
Form CMS-10141 2019 Part C and D Sample Precluded Provider Letter
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
State Eligibility Determinations (423.904(b)) and Reporting (423.910(d)) Unchanged 600102 13260 0
System Programming (Plans) (section 423.120(c)(6)) Unchanged 30 93600 0
Total burden requested under this ICR: 54427676 8670223 0  
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