Information Collection

Medicare Prescription Drug Benefit Program (Plans)

IC 187164 under ICR 201812-0938-017 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10141 Medicare Prescription Drug Benefit Program (Plans)	Form
CMS-10141.Attachments 5a-5c (Instructions) (version2).pdf	Instruction
Attachment 6d - Instructions for Drug Management Program Notices (version 2).docx	Instruction
Attachment 8a - 2020 Model Part D Explanation of Benefits (version 2).docx	Instruction
Attachment 8b - CY 2020 EOB Exhibit A (version 2).docx	Instruction
Attachment 8c - CY 2020 EOB Exhibit B (version 2).docx	Instruction
Attachment 8d - CY 2020 EOB Exhibit C (version 2).docx	Instruction
Attachment 8e - CY 2020 EOB Exhibit D (version 2).docx	Instruction
Attachment 8f - CY 2020 EOB Exhibit E (version 2).docx	Instruction
Attachment 8g - CY 2020 EOB Exhibit F (version 2).docx	Instruction
Attachment 8h - CY 2020 EOB Exhibit G (version 2).docx	Instruction
CMS-10141 Compensation Certification CMS-10141.Attachments 1a-1b (Certifications) (version 2).pdf	Form
CMS-10141 Description of Compensation Structure CMS-10141.Attachments 2a-2b (Structure Submission Form) (version 2).pdf	Form
CMS-10141 Covered Agent Information Sheets Workbook CMS-10141.Attachment_3_(Covered_Agent_Information_Sheets_Workbook) (version 2).pdf	Form
CMS-10141 Compensation Structure for Writing Agents by Contract/PB CMS-10141.Attachment_4_(Agent_Compensation_Information_Workbook)-2017 Pa....pdf	Form
CMS-10141 Initial Notice: Notice of Intent to Limit Your Access to Attachment 6a - Initial Notice (version 2).docx	Form
CMS-10141 Second Notice: Your Access to Certain Part D Drugs is Li Attachment 6b - 2nd Notice (version 2).docx	Form
CMS-10141 Alternate Second Notice Attachment 6c - Alternate 2nd Notice (version 2).docx	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	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Prescription Drug Benefit Program (Plans)

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:

table that charts list of 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) (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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 757

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	43,863,133	757	43,862,376
Annual IC Time Burden (Hours)	5,690,947	3,028	5,687,919
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.