Information Collection

Bid Pricing Tool (BPT) for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDP)-CMS-10142

IC 37926 under ICR 201912-0938-019 · OMB 0938-0944.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0944 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10142 Bid Pricing Tool (BPT) for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDP)-CMS-10142	Form
CMS-10142_Attachment_E-1_CY2021_MA_BPT_Instructions.pdf	Instruction
CMS-10142_Attachment_E-2_CY2021_Part_D_BPT_Instructions.pdf	Instruction
CMS-10142 Worksheets: Medicare Advantage Bid Pricing Tool CMS-10142_Attachment_D-1_CY2021_MA_BPT.pdf	Form
CMS-10142 Worksheets: Prescription Drug Bid Pricing Tool CMS-10142_Attachment_D-2_CY2021_PD_BPT.pdf	Form
CMS-10142_Attachment_C_BPT_changes.pdf BPT Changes	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Bid Pricing Tool (BPT) for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDP)-CMS-10142

Agency IC Tracking Number:

CM-CPC

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.308 42 CFR 422.308 42 CFR 423.350 42 CFR 422.304 42 CFR 422.324 42 CFR 423.336 42 CFR 423.315 42 CFR 423.343 42 CFR 423.346 42 CFR 423.329 42 CFR 423.322 42 CFR 422.266 42 CFR 423.279 42 CFR 423.286 42 CFR 423.293 42 CFR 422.264 42 CFR 422.252 42 CFR 422.250 42 CFR 422.254 42 CFR 422.270 42 CFR 422.256 42 CFR 422.258 42 CFR 422.262 42 CFR 422.300 42 CFR 422.306 42 CFR 423.301 42 CFR 422.310 42 CFR 422.312 42 CFR 422.314 42 CFR 422.316 42 CFR 422.318 42 CFR 422.320 42 CFR 422.322 42 CFR 423.258 42 CFR 423.265 42 CFR 423.272 42 CFR 423.251

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-10142	Worksheets: Medicare Advantage Bid Pricing Tool	CMS-10142_Attachment_D-1_CY2021_MA_BPT.pdf	Yes	Yes	Fillable Printable
Form	CMS-10142	Worksheets: Prescription Drug Bid Pricing Tool	CMS-10142_Attachment_D-2_CY2021_PD_BPT.pdf	Yes	Yes	Fillable Printable
Instruction			CMS-10142_Attachment_E-1_CY2021_MA_BPT_Instructions.pdf	Yes	No	Printable Only
Instruction			CMS-10142_Attachment_E-2_CY2021_Part_D_BPT_Instructions.pdf	Yes	No	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: 555

Number of Respondents for Small Entity: 25

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	Previously Approved
Annual Number of Responses for this IC	4,995	4,995
Annual IC Time Burden (Hours)	149,850	149,850
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
BPT Changes	CMS-10142_Attachment_C_BPT_changes.pdf	12/27/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.