Information Collection

Medicare Prescription Drug Benefit Program (Plans)

IC 187164 under ICR 201906-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 and Instruction
CMS-10141 Model Part D Explanation of Benefits Attachment 8a - 2020 Model Part D Explanation of Benefits (version 2).docx	Form and Instruction
CMS-10141 Exhibit A: Example Cover Page of the Model Part D EOB Attachment 8b - CY 2020 EOB Exhibit A (version 2).docx	Form and Instruction
CMS-10141 Exhibit B: Examples of Section 1 (the List of Prescripti Attachment 8c - CY 2020 EOB Exhibit B (version 2).docx	Form and Instruction
CMS-10141 Exhibit C: Example of Section 2 (Drug Payment Stages) Attachment 8d - CY 2020 EOB Exhibit C (version 2).docx	Form and Instruction
CMS-10141 Exhibit D: Example of Section 3 (Amounts and Definitions Attachment 8e - CY 2020 EOB Exhibit D (version 2).docx	Form and Instruction
CMS-10141 Exhibit E: Example of Section 4 (Changes to the Formular Attachment 8f - CY 2020 EOB Exhibit E (version 2).docx	Form and Instruction
CMS-10141 Exhibit F: Example of Sections 5 and 6 (Information for Attachment 8g - CY 2020 EOB Exhibit F (version 2).docx	Form and Instruction
CMS-10141 Exhibit G: Example of a Part D EOB (All Sections Include Attachment 8h - CY 2020 EOB Exhibit G (version 2).docx	Form and Instruction

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 and Instruction	CMS-10141	Model Part D Explanation of Benefits	Attachment 8a - 2020 Model Part D Explanation of Benefits (version 2).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Exhibit A: Example Cover Page of the Model Part D EOB	Attachment 8b - CY 2020 EOB Exhibit A (version 2).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Exhibit B: Examples of Section 1 (the List of Prescriptions)	Attachment 8c - CY 2020 EOB Exhibit B (version 2).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Exhibit C: Example of Section 2 (Drug Payment Stages)	Attachment 8d - CY 2020 EOB Exhibit C (version 2).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs)	Attachment 8e - CY 2020 EOB Exhibit D (version 2).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Exhibit E: Example of Section 4 (Changes to the Formulary)	Attachment 8f - CY 2020 EOB Exhibit E (version 2).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Exhibit F: Example of Sections 5 and 6 (Information for Reference)	Attachment 8g - CY 2020 EOB Exhibit F (version 2).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Exhibit G: Example of a Part D EOB (All Sections Included)	Attachment 8h - CY 2020 EOB Exhibit G (version 2).docx	Yes	Yes	Fillable Fileable

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
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	615,063,305	571,200,929	43,862,376
Annual IC Time Burden (Hours)	5,704,430	16,511	5,687,919
Annual IC Cost Burden (Dollars)	5,733,706	5,733,706	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.