Information Collection

Medicare Prescription Drug Benefit Program (PLAN)

IC 187164 under ICR 201712-0938-003 · OMB 0938-0964.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0964 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10141 Medicare Prescription Drug Benefit Program (PLAN) Form
CMS-10141.Attachments 5a-5c (Instructions).pdf Instruction
CMS-10141 Compensation Certification CMS-10141.Attachments 1a-1b (Certifications).pdf Form
CMS-10141 Description of Compensation Structure CMS-10141.Attachments 2a-2b (Structure Submission Form).pdf Form
CMS-10141 Covered Agent Information Sheets Workbook CMS-10141.Attachment_3_(Covered_Agent_Information_Sheets_Workbook)2013 Part D (10).pdf Form
CMS-10141 Compensation Structure for Writing Agents by Contract/PB CMS-10141.Attachment_4_(Agent_Compensation_Information_Workbook)-2017 Part D PRA (002).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Prescription Drug Benefit Program (PLAN)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10141	Compensation Certification	CMS-10141.Attachments 1a-1b (Certifications).pdf	Yes	Yes	Fillable Fileable
Instruction			CMS-10141.Attachments 5a-5c (Instructions).pdf	Yes	Yes	Paper Only
Form	CMS-10141	Description of Compensation Structure	CMS-10141.Attachments 2a-2b (Structure Submission Form).pdf	Yes	Yes	Fillable Fileable
Form	CMS-10141	Covered Agent Information Sheets Workbook	CMS-10141.Attachment_3_(Covered_Agent_Information_Sheets_Workbook)2013 Part D (10).pdf	Yes	Yes	Fillable Printable
Form	CMS-10141	Compensation Structure for Writing Agents by Contract/PBP Number	CMS-10141.Attachment_4_(Agent_Compensation_Information_Workbook)-2017 Part D PRA (002).pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,949	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	79,544,700	35,685,515	8,374,442	35,484,743
Annual IC Time Burden (Hours)	5,807,772	224,235	922,524	4,661,013
Annual IC Cost Burden (Dollars)	0	0	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.