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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
15000
1245
0
Form and Instruction
CMS-10141
Model Precluded Provider Letter
Business Continuity Plans under 422.504(o) and 423.505(p)
Modified
99
4960
0
Medicare Prescription Drug Benefit Program (Benes)
Modified
4630100
1157525
0
Medicare Prescription Drug Benefit Program (Plans)
Modified
662883048
53332340
584811068
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
Form and Instruction
CMS-10141
Model Prescriber Inquiry Letter
Form and Instruction
CMS-10141
Model Sponsor Information Transfer Memo
Form and Instruction
CMS-10141
3a - 2022 Model Part D Explanation of Benefits (All Sections Included)
Form and Instruction
CMS-10141
3b - Exhibit A: Example Cover Page of the Model Part D EOB
Form and Instruction
CMS-10141
3c - Exhibit B: Examples of Section 1 (the List of Prescriptions)
Form and Instruction
CMS-10141
3d - Exhibit C: Example of Section 2 (Drug Payment Stages)
Form and Instruction
CMS-10141
3e - Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs)
Form and Instruction
CMS-10141
3f - Exhibit E: Example of Section 4 (Changes to the Formulary)
Form and Instruction
CMS-10141
3g - Exhibit F: Example of Sections 5 and 6 (Information for Reference)
Form and Instruction
CMS-10141
3h - Exhibit G: Example of a Part D EOB (All Sections Included)
State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))
Unchanged
600102
13260
0
Total burden requested under this ICR:
668128349
54509330
584811068
To view an IC, click on IC Title