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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
Instruction
Attachment 1a. Instructions for Drug Management Program Notices.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
Initial Notice Sent to Potentially At-Risk Beneficiaries
Attachment 1b. Initial DMP Notice.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
Second Notice Sent to Beneficiary Designating At-Risk Status
Attachment 1c. Second DMP Notice.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
Alternate Second Notice Sent to Beneficiary Not Considered At-Risk
Attachment 1d. Alternate 2nd Notice.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
Model Prescriber Inquiry Letter
Attachment 1e. Model Prescriber Inquiry Letter.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
Model Sponsor Information Transfer Memo
Attachment 1f. Model Sponsor Information Transfer Memo.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
3a - 2022 Model Part D Explanation of Benefits (All Sections Included)
Attachment 3a. CY 2022 EOB.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
3b - Exhibit A: Example Cover Page of the Model Part D EOB
Attachment 3b. CY 2022 EOB Exhibit A.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
3c - Exhibit B: Examples of Section 1 (the List of Prescriptions)
Attachment 3c. CY 2022 EOB Exhibit B.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
3d - Exhibit C: Example of Section 2 (Drug Payment Stages)
Attachment 3d. CY 2022 EOB Exhibit C.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
3e - Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs)
Attachment 3e. CY 2022 EOB Exhibit D.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
3f - Exhibit E: Example of Section 4 (Changes to the Formulary)
Attachment 3f. CY 2022 EOB Exhibit E.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
3g - Exhibit F: Example of Sections 5 and 6 (Information for Reference)
Attachment 3g. CY 2022 EOB Exhibit F.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10141
3h - Exhibit G: Example of a Part D EOB (All Sections Included)
Attachment 3h - Exhibit G - Example of a PartD-EOB- (all sections included) 30 day comment version.pdf
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:
942
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
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
662,883,048
0
-102
0
0
662,883,150
Annual IC Time Burden (Hours)
53,332,340
0
47,204,136
0
0
6,128,204
Annual IC Cost Burden (Dollars)
584,811,068
0
578,558,395
0
0
6,252,673
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.