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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Medicare Prescription Drug Benefit Program (Plans)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
42 CFR 423
Information Collection Instruments:
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
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
912
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
616,933,733
0
1,870,428
0
0
615,063,305
Annual IC Time Burden (Hours)
9,178,691
0
3,474,261
0
0
5,704,430
Annual IC Cost Burden (Dollars)
5,751,142
0
17,436
0
0
5,733,706
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.