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)) Modified 95000 7885 0 Other-Part C and D Sample Precluded Provider Letter
Business Continuity Plans under 422.504(o) and 423.505(p) Modified 99 15920 0 Form CMS-10141 Compensation Certifications
Form CMS-10141 Structure Submission Forms
Form CMS-10141 Covered Agent Information Sheet
Form CMS-10141 Compensation Structure for Writing Agents by Contract/PBP Number
Instruction
Creation of Model Notices (Plans) (section 423.120(c)(6)) Modified 212 636 0 Instruction
Form and Instruction CMS-10141 Initial Notice Sent to Potentially At-Risk Beneficiaries
Form and Instruction CMS-10141 Second Notice Sent to Beneficiary Designating At-Risk Status
Form and Instruction CMS-10141 Alternate Second Notice Sent to Beneficiary Not Considered At-Risk
Medicare Prescription Drug Benefit Program (Benes) Modified 9869100 2847975 0
Medicare Prescription Drug Benefit Program (Plans) Modified 615063305 5704430 5733706 Form and Instruction CMS-10141 Model Part D Explanation of Benefits
Form and Instruction CMS-10141 Exhibit A: Example Cover Page of the Model Part D EOB
Form and Instruction CMS-10141 Exhibit B: Examples of Section 1 (the List of Prescriptions)
Form and Instruction CMS-10141 Exhibit C: Example of Section 2 (Drug Payment Stages)
Form and Instruction CMS-10141 Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs)
Form and Instruction CMS-10141 Exhibit E: Example of Section 4 (Changes to the Formulary)
Form and Instruction CMS-10141 Exhibit F: Example of Sections 5 and 6 (Information for Reference)
Form and Instruction CMS-10141 Exhibit G: Example of a Part D EOB (All Sections Included)
State Eligibility Determinations (423.904(b)) and Reporting (423.910(d)) Modified 600102 13260 0
System Programming (Plans) (section 423.120(c)(6)) Modified 30 93600 0
Total burden requested under this ICR: 625627848 8683706 5733706  
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