OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Medicare Prescription Drug Benefit Program (Plans)

IC 187164 under ICR 201812-0938-017 · OMB 0938-0964.

Documents and Forms
Document Name
Document Type
Form
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form
Form
Form
Form
Form
Form
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

Medicare Prescription Drug Benefit Program (Plans)
 
No Modified
 
Mandatory
 
42 CFR 423

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10141 Compensation Certification CMS-10141.Attachments 1a-1b (Certifications) (version 2).pdf Yes Yes Fillable Fileable
Instruction CMS-10141.Attachments 5a-5c (Instructions) (version2).pdf Yes Yes Paper Only
Form CMS-10141 Description of Compensation Structure CMS-10141.Attachments 2a-2b (Structure Submission Form) (version 2).pdf Yes Yes Fillable Fileable
Form CMS-10141 Covered Agent Information Sheets Workbook CMS-10141.Attachment_3_(Covered_Agent_Information_Sheets_Workbook) (version 2).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 Pa....pdf Yes Yes Fillable Printable
Form CMS-10141 Initial Notice: Notice of Intent to Limit Your Access to Certain Part D Drugs Attachment 6a - Initial Notice (version 2).docx Yes Yes Fillable Fileable
Form CMS-10141 Second Notice: Your Access to Certain Part D Drugs is Limited Attachment 6b - 2nd Notice (version 2).docx Yes Yes Fillable Fileable
Form CMS-10141 Alternate Second Notice Attachment 6c - Alternate 2nd Notice (version 2).docx Yes Yes Fillable Fileable
Instruction Attachment 6d - Instructions for Drug Management Program Notices (version 2).docx Yes Yes Printable Only
Form CMS-10141 2019 Part C and D Sample Precluded Provider Letter Attachment 7a - 2019 Part C and D Sample Precluded Provider Letter (version 2).docx Yes No Fillable Fileable
Instruction Attachment 8a - 2020 Model Part D Explanation of Benefits (version 2).docx Yes Yes Printable Only
Instruction Attachment 8b - CY 2020 EOB Exhibit A (version 2).docx Yes Yes Printable Only
Instruction Attachment 8c - CY 2020 EOB Exhibit B (version 2).docx Yes Yes Printable Only
Instruction Attachment 8d - CY 2020 EOB Exhibit C (version 2).docx Yes Yes Printable Only
Instruction Attachment 8e - CY 2020 EOB Exhibit D (version 2).docx Yes Yes Printable Only
Instruction Attachment 8f - CY 2020 EOB Exhibit E (version 2).docx Yes Yes Printable Only
Instruction Attachment 8g - CY 2020 EOB Exhibit F (version 2).docx Yes Yes Printable Only
Instruction Attachment 8h - CY 2020 EOB Exhibit G (version 2).docx Yes Yes Printable Only

Health Health Care Services

 

757 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 43,863,133 0 757 0 0 43,862,376
Annual IC Time Burden (Hours) 5,690,947 0 3,028 0 0 5,687,919
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.