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OMB Control No: 0938-0975	ICR Reference No: 201804-0938-011
Status: Historical Active	Previous ICR Reference No: 201709-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Standardized Pharmacy Notice: Your Prescription Cannot be Filled (f/k/a Medicare Prescription Drug Coverage and Your Rights) (CMS-10147)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/14/2018
	Date Received in OIRA: 04/17/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2021	02/28/2021	02/28/2021
Responses	40,100,000	0	40,100,000
Time Burden (Hours)	668,066	0	668,066
Cost Burden (Dollars)	0	0	0

Abstract: Pursuant to 42 CFR 423.562(a)(3) and 423.128(b)(7)(iii), Part D plan sponsors must arrange with their network pharmacies to provide a printed copy of the standardized pharmacy notice to enrollees (beneficiaries) at the point of sale when an enrollee's prescription cannot be filled.

Authorizing Statute(s): Statute at Large: 18 Stat. 1860
Statute at Large: 18 Stat. 1852

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 16843	04/06/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 37453	08/10/2017
Did the Agency receive public comments on this ICR? Yes

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Standardized Pharmacy Notice	CMS-10147, CMS-10147	,

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	40,100,000	40,100,000
Annual Time Burden (Hours)	668,066	668,066
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: We propose to revise the notice and accompanying instructions to enhance the clarity and accuracy of the notice and instructions. We also propose to add language that informs beneficiaries of their rights under Section 504 of the Rehabilitation Act of 1973 (Section 504), by alerting the beneficiary to CMS’s nondiscrimination practices and the availability of alternate forms of this notice, if needed. The annual hourly burden associated with this collection is estimated to be 668,066 hours. The annual hourly burden in the 2014 PRA submission for this collection was 626,749 hours. The 41,317 hour increase in burden is an adjustment that is based on the increased number of applicable pharmacies (+6,000 pharmacies) and the increased number of standardized pharmacy notices (+2,479,760 notices) that are likely to be distributed based on CY 2016 prescription drug event data. Reconciling the burden increase: 41,313 hr = 2,479,760 x 0.01666. We attribute the 4 hour difference (41,317 hr – 41,313 hr) to 1 min/response rounding differences (when converted to hours) between this 2017 iteration and the currently approved 2014 iteration. We are also adjusting our cost estimates based on current BLS wage data for pharmacy technicians. In this iteration we are doubling that wage to account for burden and overhead.

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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