Information Collection

Solicitation for Applications for Medicare Prescription Drug Plan 2021 Contracts

IC 43672 under ICR 201912-0938-006 · OMB 0938-0936.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0936 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10137 Solicitation for Applications for Medicare Prescription Drug Plan 2021 Contracts	Form and Instruction
CMS-10137 Solicitation for Application for Medicare Prescription D 2021 Part D Application_PRA_v30day_CLEAN.pdf	Form and Instruction
CMS-10137 PACE Medicare Part D Application 2020 PACE Part D Application PRA_v30day CLEAN.pdf	Form and Instruction

IC Title:

Solicitation for Applications for Medicare Prescription Drug Plan 2021 Contracts

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.514 42 CFR 423.512 42 CFR 423.112 42 CFR 423.120 42 CFR 423.440 42 CFR 423.153

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10137	Solicitation for Application for Medicare Prescription Drug Plan 2021 Contracts	2021 Part D Application_PRA_v30day_CLEAN.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10137	PACE Medicare Part D Application	2020 PACE Part D Application PRA_v30day CLEAN.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 290

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	290	34	256
Annual IC Time Burden (Hours)	1,385	-966	2,351
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.