Medicare Prescription Drug Benefit Program (Plan)

Medicare Prescription Drug Benefit Program

CMS-10141.Attachments 2a-2b (Structure Submission Form)-11-07-08

Medicare Prescription Drug Benefit Program (Plan)

OMB: 0938-0964

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Attachment 2a - Description of Compensation Structure for Plans Using Contracted Marketing Organizations

The structures to be provided are the initial and renewal compensation amounts paid by the plan to the contracted marketing organization(s).

(Optional form - if your organization has the schedule(s) in a workbook, or some other format, you may submit that documentation in lieu of Attachment 2a)



Contracted Marketing Organization Compensation Schedule (Submit one per schedule)

<MA or PDP Organization Name>

<Contract Number(s)>

<Year>

<Unique Identifying Number>



Initial Compensation Structure:






Renewal Compensation Structure:





Attachment 2b - Description of Compensation Structure for Writing Agents Paid Directly by the MA or PDP Organization, and by Contracted Marketing Organizations

The structures to be provided are the initial and renewal compensation amounts paid directly to the writing agents by MA and PDP organizations. In addition, provide structures for the initial and renewal compensations amounts paid directly to the writing agents by marketing organization(s) contracted by the plans.

(Optional form - if your organization has the schedule(s) in a workbook, or some other format, you may submit that documentation in lieu of Attachment 2b)




Writing Agents Compensation Schedule

(Submit one per schedule)

<MA or PDP Organization Name>

<Contract Number(s)>

<Year>

<Unique Identifying Number>




Initial Compensation Structure:







Renewal Compensation Structure:


PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is

0938-0964. The time required to complete this information collection is estimated to average 49 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.





File Typeapplication/msword
File TitleAttachment 1 - Compensation Certification
AuthorGerard Mulcahy
Last Modified ByCMS_DU
File Modified2008-11-07
File Created2008-11-07

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