Information Collection

Manufacturer Submission of Average Sales Price (ASP) Data for Medicare Part B Drugs and Biological and Supporting Regulations (CMS-10110)

IC 8767 under ICR 200904-0938-009 · OMB 0938-0921.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0921 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10110 Proposed Revised Addendum A Manufacturer Submission of Average Sales Price (ASP) Data for Medicare Part B Drugs and Biological and Supporting Regulations (CMS-10110)	Form
Appendix A data elements guide revised 110108.doc	Instruction
CMS-10110 Proposed Revised Addendum A ASPData revised _AddendumA revised 2009 112108.xls	Form
ASPData revised _AddendumA revised 2009 110108.csv ASPData revised _AddendumA revised 2009 110108	IC Document
Addendum B document for 2009 renewal 112108.doc Addendum B document for 2009 renewal 112108	IC Document
ASPData revised _AddendumA revised 2009 with example data 110108.csv ASPData revised _AddendumA revised 2009 with example data 110108	IC Document
ASPData revised _AddendumA revised 2009 with example data 112108.xls ASPData revised _AddendumA revised 2009 with example data 112108	IC Document
Addendum B track changes document for 2009 renewal 112108.doc Addendum B track changes document for 2009 renewal 112108	IC Document

IC Title:

Manufacturer Submission of Average Sales Price (ASP) Data for Medicare Part B Drugs and Biological and Supporting Regulations (CMS-10110)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414 Subpart J Section 800-806

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction					Yes	Yes	Paper Only
Form	CMS-10110				Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 180

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	720	240	480
Annual IC Time Burden (Hours)	28,800	11,040	17,760
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ASPData revised _AddendumA revised 2009 110108		03/09/2009
Addendum B document for 2009 renewal 112108		03/09/2009
ASPData revised _AddendumA revised 2009 with example data 110108		03/09/2009
ASPData revised _AddendumA revised 2009 with example data 112108		03/09/2009
Addendum B track changes document for 2009 renewal 112108		03/09/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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