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 201112-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Average Sales Price (ASP) Addendum A Manufacturer Submission of Average Sales Price (ASP) Data for Medicare Part B Drugs and Biological and Supporting Regulations (CMS-10110)	Form
LabelerTemplate Users Guide_DRAFT for approval.pdf	Instruction
CMS-10110 Average Sales Price (ASP) Addendum A TestASPAddendumAMacro_DRAFT for approval.xlsm	Form
CROSSWALK DOCUMENT FOR CMS 10110 FINAL.docx CMS-10110 Crosswalk	IC Document
Disclosure Statement FINAL.docx Disclosure Statement FINAL	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
Form	CMS-10110				Yes	Yes	Fillable Printable
Instruction					Yes	No	Printable 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	0	720
Annual IC Time Burden (Hours)	34,560	5,760	28,800
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10110 Crosswalk		12/05/2011
Disclosure Statement FINAL		12/05/2011

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

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