Information Collection

Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers (CMS-10171)

IC 8840 under ICR 201702-0938-016 · OMB 0938-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0978 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 1_Transaction Facilitation.pdf	Instruction
2014 SPAP cover_62613.pdf	Instruction
CMS-10171 2017 SPAP Template Attachment 2_2017 SPAP template [rev 02-24-2017 by OSORA PRA].pdf	Form

IC Title:

Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers (CMS-10171)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.464

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attachment 1_Transaction Facilitation.pdf	Yes	Yes	Fillable Printable
Form	CMS-10171	2017 SPAP Template	Attachment 2_2017 SPAP template [rev 02-24-2017 by OSORA PRA].pdf	Yes	Yes	Fillable Printable
Instruction			2014 SPAP cover_62613.pdf	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 63,910

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	770,856,393	768,453,811	2,402,582
Annual IC Time Burden (Hours)	938,061	-4,267,067	5,205,128
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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