Information Collection

Solicitation for Applications for Medicare Prescription Drug Plan 2022 Contracts

IC 43672 under ICR 202101-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 2022 Contracts	Form and Instructi
CMS-10137 Solicitation for Application for Medicare Prescription D 2022 Part D Application.pdf	Form and Instruction
CMS-10137 Solicitation for Application for Medicare Prescription D 2022 Part D Application.pdf	Form and Instruction
CMS-10137 PACE Medicare Part D Application 2021 PACE Part D Application.pdf	Form and Instruction
CMS-10137 PACE Medicare Part D Application 2021 PACE Part D Application.pdf	Form and Instruction

IC Title:

Solicitation for Applications for Medicare Prescription Drug Plan 2022 Contracts

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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

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 2022 Contracts	2022 Part D Application.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10137	PACE Medicare Part D Application	2021 PACE Part D Application.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 658

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	331	41	290
Annual IC Time Burden (Hours)	1,550	165	1,385
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.