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 102 4680 0
Medicare Prescription Drug Benefit Program (Benes) Modified 4630100 1157525 0
Medicare Prescription Drug Benefit Program (Plans) Modified 690557096 24330233 599698399 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)) Modified 600102 13260 0
Total burden requested under this ICR: 695802400 25506943 599698399  
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