Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0976 can be found here:

Documents and Forms

Document Name Document Type
Denial Notice Instructions 2020 60 day v508.pdf Instruction
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co Denial Notice 2020 30 day FINAL.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.580 42 CFR 423.582 42 CFR 423.568(c) 42 CFR 423.568(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Denial Notice Instructions 2020 60 day v508.pdf		No		Printable Only
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage	Denial Notice 2020 30 day FINAL.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 525	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,887,866	985,811	1,902,055
Annual IC Time Burden (Hours)	721,967	246,453	475,514
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.