Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)

Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0976 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10146(SP) Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP) Form and Instruction
Denial_Notice_Instructions_rev 03 03 2017 clean.docx Instruction
CMS-10146(SP) Notice of Denial of Medicare Prescription Drug Coverage Denial Notice Spanish2013v508.pdf Form and Instruction
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co Denial Notice_rev 03 01 2017 clean.docx Form

Information Collection (IC) Details

IC Title:	Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.568(d) 42 CFR 423.580 42 CFR 423.582 42 CFR 423.568(c)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10146(SP)	Notice of Denial of Medicare Prescription Drug Coverage	Denial Notice Spanish2013v508.pdf	Yes	No	Fillable Printable
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage (English)	Denial Notice_rev 03 01 2017 clean.docx	No		Fillable Printable
Instruction			Denial_Notice_Instructions_rev 03 03 2017 clean.docx	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 580	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,902,055	1,902,055
Annual IC Time Burden (Hours)	475,514	475,514
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.