View Information Collection (IC)

View Information Collection (IC)

Medicare Prescription Drug Benefit Program (Plans)
 
No Modified
 
Mandatory
 
42 CFR 423

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10141 Model Part D Explanation of Benefits Attachment 8a - 2020 Model Part D Explanation of Benefits (version 2).docx Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Exhibit A: Example Cover Page of the Model Part D EOB Attachment 8b - CY 2020 EOB Exhibit A (version 2).docx Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Exhibit B: Examples of Section 1 (the List of Prescriptions) Attachment 8c - CY 2020 EOB Exhibit B (version 2).docx Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Exhibit C: Example of Section 2 (Drug Payment Stages) Attachment 8d - CY 2020 EOB Exhibit C (version 2).docx Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs) Attachment 8e - CY 2020 EOB Exhibit D (version 2).docx Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Exhibit E: Example of Section 4 (Changes to the Formulary) Attachment 8f - CY 2020 EOB Exhibit E (version 2).docx Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Exhibit F: Example of Sections 5 and 6 (Information for Reference) Attachment 8g - CY 2020 EOB Exhibit F (version 2).docx Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Exhibit G: Example of a Part D EOB (All Sections Included) Attachment 8h - CY 2020 EOB Exhibit G (version 2).docx Yes Yes Fillable Fileable

Health Health Care Services

 

757 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 615,063,305 0 571,200,929 0 0 43,862,376
Annual IC Time Burden (Hours) 5,704,430 0 16,511 0 0 5,687,919
Annual IC Cost Burden (Dollars) 5,733,706 0 5,733,706 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.