Information Collection

Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers

IC 8840 under ICR 202011-0938-014 · OMB 0938-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0978 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 1_Transaction Facilitation.pdf	Instruction
SPAPQuickReferenceGuide (1).pdf	Instruction
CMS-10171 2021 SPAP Template Release of the 2021 State Pharmaceutical Assistance and AIDS Drug Assistance Programs SPAP ADAP Module.pdf	Form

IC Title:

Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.464

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
Instruction			Attachment 1_Transaction Facilitation.pdf	Yes	Yes	Fillable Printable
Form	CMS-10171	2021 SPAP Template	Release of the 2021 State Pharmaceutical Assistance and AIDS Drug Assistance Programs SPAP ADAP Module.pdf	Yes	Yes	Fillable Printable
Instruction			SPAPQuickReferenceGuide (1).pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 62,062

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	748,566,570	-22,289,823	770,856,393
Annual IC Time Burden (Hours)	938,968	907	938,061
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.