ICR Documents

Supporting Statement A Document Date Uploaded CMS-10141 - Supporting Statement A (CMS-4190-F1 and F2 version 7).docx 11/09/2021 Supporting Statement B Document Date Uploaded Supplementary Documents Title Document Document Type Date Uploaded 1a – Crosswalk for Instructions for Drug Management Program Notices Attachment 1a. Crosswalk for Instructions for Drug Management Program Notices.pdf Supplementary Document 11/09/2021 1b – Crosswalk for Initial Drug Management Program Notice Attachment 1b. Crosswalk for Initial Drug Management Program Notice.pdf Supplementary Document 12/22/2021 1c – Crosswalk for Second Drug Management Program Notice Attachment 1c. Crosswalk for Second Drug Management Program Notice.pdf Supplementary Document 12/22/2021 1d – Crosswalk for Alternate Second Drug Management Program Notice Attachment 1d. Crosswalk for Alternate Second Drug Management Program Notice.pdf Supplementary Document 11/09/2021 1e – 60-Day Crosswalk for Model Prescriber Inquiry Letter Attachment 1e. 60-Day Crosswalk for Model Prescriber Inquiry Letter.pdf Supplementary Document 11/09/2021 1f – 60-Day Crosswalk for Model Sponsor Information Transfer Memo Attachment 1f. 60-Day Crosswalk for Model Sponsor Information Transfer Memo.pdf Supplementary Document 11/09/2021 Attachment 2 – Crosswalk for Model Precluded Provider Letter Attachment 2. Crosswalk for Model Precluded Provider Letter.pdf Supplementary Document 11/09/2021 3 - Crosswalk for EOB and Exhibits Attachment 3. Crosswalk CY 2022 EOB.pdf Supplementary Document 11/09/2021 Response to 60-day Comments 60 Day Comments and Responses.docx Supplementary Document 11/09/2021 Public Comments Author Name Comment Document Author Affiliation Sponsoring Org. Type Category Date of Comment Date Comment Received , Anonymous ktl-ulkg-ra21 - Combined Cover and Comment.pdf Prime Therapeutics Other -- Web Simple 09/15/2021 09/15/2021 Hitchon, Jennifer ktm-6cvw-hdfh - Comments.pdf CVS Health Other -- Web Simple 09/15/2021 09/15/2021 Rieger, Tyler kts-zlw9-e8vv - Combined Cover and Comment.pdf Other -- Simple 09/20/2021 09/20/2021 Crimmins, Michelle ktt-6j1s-u8kd - Combined Cover and Comment.pdf ktt-6j1s-u8kd - Comment Attachment.pdf UnitedHealthcare Other -- Web Simple 09/20/2021 09/20/2021