Standardized Pharmacy Notice: Your Prescription Cannot be Filled (f/k/a Medicare Prescription Drug Coverage and Your Rights)

ICR 201203-0938-003

OMB: 0938-0975

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Justification for No Material/Nonsubstantive Change
2012-03-09
Supporting Statement A
2012-03-09
IC Document Collections
IC ID
Document
Title
Status
37927 Modified
ICR Details
0938-0975 201203-0938-003
Historical Active 201109-0938-005
HHS/CMS
Standardized Pharmacy Notice: Your Prescription Cannot be Filled (f/k/a Medicare Prescription Drug Coverage and Your Rights)
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 03/12/2012
Retrieve Notice of Action (NOA) 03/10/2012
  Inventory as of this Action Requested Previously Approved
01/31/2015 01/31/2015 01/31/2015
37,087,402 0 37,087,402
617,876 0 617,876
0 0 0

Pursuant to 42 C.F.R. ? 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.

Statute at Large: 18 Stat. 1860 Name of Statute: null
   Statute at Large: 18 Stat. 1852 Name of Statute: null
  
None

Not associated with rulemaking

Yes

1
IC Title Form No. Form Name
Standardized Pharmacy Notice CMS-10147, CMS-10147 CMS-10147_Pharmacy_Notice_ ,   CMS-10147.Pharnacy Notice - Spanish Version

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 37,087,402 37,087,402 0 0 0 0
Annual Time Burden (Hours) 617,876 617,876 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
No
No
No
Uncollected
William Parham 4107864669

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/10/2012


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