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Agenda
Reg Review
ICR
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
To view an IC, click on IC Title