Comprehensive Addiction and Recovery Act of 2016 (CARA) / Medicare Prescription Drug Benefit Program (CMS-10141)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10410 Model Precluded Provider Letter	Form and Instruction	Modified	Available
Form CMS-10410 Preparation and Issuance of Model Notices (section 423.120(c)(6))	Form and Instruction	Modified	Repair queued
Form CMS-10141 Alternate Second Notice Sent to Beneficiary Not Considered At-Risk	Form and Instruction	Removed	Available
Form CMS-10141 Second Notice Sent to Beneficiary Designating At-Risk Status	Form and Instruction	Removed	Available
Form CMS-10141 Initial Notice Sent to Potentially At-Risk Beneficiaries	Form and Instruction	Removed	Available
Form CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections Included)	Form and Instruction	Modified	Repair queued
Form CMS-10141 3g - Exhibit F: Example of Sections 5 and 6 (Information for Reference)	Form and Instruction	Modified	Repair queued
Form CMS-10141 3f - Exhibit E: Example of Section 4 (Changes to the Formulary)	Form and Instruction	Modified	Repair queued
Form CMS-10141 3e - Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs)	Form and Instruction	Modified	Available
Form CMS-10141 3d - Exhibit C: Example of Section 2 (Drug Payment Stages)	Form and Instruction	Modified	Available
Form CMS-10141 3c - Exhibit B: Examples of Section 1 (the List of Prescriptions)	Form and Instruction	Modified	Available
Form CMS-10141 3b - Exhibit A: Example Cover Page of the Model Part D EOB	Form and Instruction	Modified	Repair queued
Form CMS-10141 3a - 2022 Model Part D Explanation of Benefits (All Sections Included)	Form and Instruction	Modified	Repair queued
Form CMS-10141 Model Sponsor Information Transfer Memo	Form and Instruction	Modified	Available
Form CMS-10141 Model Prescriber Inquiry Letter	Form and Instruction	Modified	Repair queued
Form CMS-10141 Alternate Second Notice Sent to Beneficiary Not Considered At-Risk	Form and Instruction	Modified	Repair queued
Form CMS-10141 Second Notice Sent to Beneficiary Designating At-Risk Status	Form and Instruction	Modified	Available
Form CMS-10141 Initial Notice Sent to Potentially At-Risk Beneficiaries	Form and Instruction	Modified	Available
CMS-10141 - Supporting Statement A (CMS-4190-F1 and F2 version 7).docx	Supporting Statement A	Uploaded 2021-11-09	Repair queued
60 Day Comments and Responses.docx	Supplementary Document	Uploaded 2021-11-09	Repair queued
Attachment 3. Crosswalk CY 2022 EOB.pdf	Supplementary Document	Uploaded 2021-11-09	Repair queued
Attachment 2. Crosswalk for Model Precluded Provider Letter.pdf	Supplementary Document	Uploaded 2021-11-09	Repair queued
Attachment 1f. 60-Day Crosswalk for Model Sponsor Information Transfer Memo.pdf	Supplementary Document	Uploaded 2021-11-09	Repair queued
Attachment 1e. 60-Day Crosswalk for Model Prescriber Inquiry Letter.pdf	Supplementary Document	Uploaded 2021-11-09	Repair queued
Attachment 1d. Crosswalk for Alternate Second Drug Management Program Notice.pdf	Supplementary Document	Uploaded 2021-11-09	Repair queued
Attachment 1c. Crosswalk for Second Drug Management Program Notice.pdf	Supplementary Document	Uploaded 2021-11-09	Repair queued
Attachment 1b. Crosswalk for Initial Drug Management Program Notice.pdf	Supplementary Document	Uploaded 2021-11-09	Repair queued
Attachment 1a. Crosswalk for Instructions for Drug Management Program Notices.pdf	Supplementary Document	Uploaded 2021-11-09	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8823	Medicare Prescription Drug Benefit Program (Benes)		Modified
231341	Preparation and Issuance of Model Notices (section 423.120(c)(6))	Form and Instruction	Modified	Model Precluded Provider Letter
231341	Preparation and Issuance of Model Notices (section 423.120(c)(6))	Form and Instruction	Modified
231340	Creation of Model Notices (Plans) (section 423.120(c)(6))	Form and Instruction	Removed	Alternate Second Notice Sent to Beneficiary Not Considered At-Risk
231340	Creation of Model Notices (Plans) (section 423.120(c)(6))	Form and Instruction	Removed	Second Notice Sent to Beneficiary Designating At-Risk Status
231340	Creation of Model Notices (Plans) (section 423.120(c)(6))	Form and Instruction	Removed	Initial Notice Sent to Potentially At-Risk Beneficiaries
231340	Creation of Model Notices (Plans) (section 423.120(c)(6))	Instruction	Removed
231339	System Programming (Plans) (section 423.120(c)(6))		Removed
217122	Business Continuity Plans under 422.504(o) and 423.505(p)		Modified
209891	State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))		Unchanged
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3h - Exhibit G: Example of a Part D EOB (All Sections Included)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3g - Exhibit F: Example of Sections 5 and 6 (Information for Reference)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3f - Exhibit E: Example of Section 4 (Changes to the Formulary)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3e - Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3d - Exhibit C: Example of Section 2 (Drug Payment Stages)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3c - Exhibit B: Examples of Section 1 (the List of Prescriptions)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3b - Exhibit A: Example Cover Page of the Model Part D EOB
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3a - 2022 Model Part D Explanation of Benefits (All Sections Included)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	Model Sponsor Information Transfer Memo
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	Model Prescriber Inquiry Letter
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	Alternate Second Notice Sent to Beneficiary Not Considered At-Risk
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	Second Notice Sent to Beneficiary Designating At-Risk Status
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	Initial Notice Sent to Potentially At-Risk Beneficiaries
187164	Medicare Prescription Drug Benefit Program (Plans)	Instruction	Modified

ICR Details

OMB Control No: 0938-0964	ICR Reference No: 202110-0938-012
Status: Historical Active	Previous ICR Reference No: 201906-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Comprehensive Addiction and Recovery Act of 2016 (CARA) / Medicare Prescription Drug Benefit Program (CMS-10141)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/07/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/09/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2025	36 Months From Approved	01/31/2022
Responses	666,813,366	0	625,627,848
Time Burden (Hours)	6,973,844	0	8,683,706
Cost Burden (Dollars)	6,252,673	0	5,733,706

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Abstract: Part D plans and, to the extent applicable, MA organizations will use the information discussed below to comply with the eligibility and other requirements associated with their participation in Part D. CMS will use this information from plan sponsors and States to approve contract applications, monitor compliance with contract requirements, make proper payment to plans, and ensure that correct information is disclosed to potential and current enrollees. The new information collection will allow CMS to ensure sponsors have plans in place to restore business operations following a disruption of regular operations. Medicare beneficiaries will use the information provided by the Part D sponsors to make decisions regarding Part D enrollment as well as grievance and appeal requests. Under CMS-4182-P (RIN 0938-AT08), CMS will make the Preclusion List available to Part D sponsors. The Part D sponsors will perform system programming to maintain the Preclusion List in order to reject a pharmacy claim (or deny a beneficiary request for reimbursement) for a Part D drug that is prescribed by an individual on the Preclusion List. CMS will create and disseminate model notices to the prescribers to notify them of their existence on the Preclusion List, while the Part D sponsors will create and disseminate model notices to the Medicare beneficiaries to notify them that the pharmacy claim is being rejected or denied due to the prescriber’s existence on the Preclusion List.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 101 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
   Statute at Large: 18 Stat. 1860
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 101 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT97	Final or interim final rulemaking	86 FR 5864	01/19/2021

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 38485	07/21/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 59165	10/26/2021
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Preparation and Issuance of Model Notices (section 423.120(c)(6))	CMS-10410	Model Precluded Provider Letter
Business Continuity Plans under 422.504(o) and 423.505(p)
Creation of Model Notices (Plans) (section 423.120(c)(6))	CMS-10141, CMS-10141, CMS-10141	Initial Notice Sent to Potentially At-Risk Beneficiaries ,   Second Notice Sent to Beneficiary Designating At-Risk Status ,   Alternate Second Notice Sent to Beneficiary Not Considered At-Risk
Medicare Prescription Drug Benefit Program (Benes)
Medicare Prescription Drug Benefit Program (Plans)	CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141	Initial Notice Sent to Potentially At-Risk Beneficiaries ,   Second Notice Sent to Beneficiary Designating At-Risk Status ,   Alternate Second Notice Sent to Beneficiary Not Considered At-Risk ,   Model Prescriber Inquiry Letter ,   Model Sponsor Information Transfer Memo ,   3a - 2022 Model Part D Explanation of Benefits (All Sections Included) ,   3b - Exhibit A: Example Cover Page of the Model Part D EOB ,   3c - Exhibit B: Examples of Section 1 (the List of Prescriptions) ,   3d - Exhibit C: Example of Section 2 (Drug Payment Stages) ,   3e - Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs) ,   3f - Exhibit E: Example of Section 4 (Changes to the Formulary) ,   3g - Exhibit F: Example of Sections 5 and 6 (Information for Reference) ,   3h - Exhibit G: Example of a Part D EOB (All Sections Included)
State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))
System Programming (Plans) (section 423.120(c)(6))

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	666,813,366	625,627,848	0	-4,648,787	45,834,305	0
Annual Time Burden (Hours)	6,973,844	8,683,706	0	-1,761,858	51,996	0
Annual Cost Burden (Dollars)	6,252,673	5,733,706	0	518,967	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The current burden sets out 625,627,848 responses and 8,683,706 hours. We are revising this estimate to 666,813,366 responses and 6,973,844 hours (see Table 15). Total responses increased by 41,185,518 annually, however the annual burden hours decreased by 1,709,862 hours. The net change in burden reflects the addition and removal of ICRs as well as changes in burden associated with existing ICRs updated to reflect the current numbers of Part D contracts. There was a net increase of 32,697,465 responses as a result of the addition and removal of ICRs from this package. The additional 8,488,053 responses (41,185,518 minus 32,697,465) is due to the increased number of Part D contracts in 2021 compared with the number of contracts in the previously approved supporting statement (942 vs 757, respectively). Similarly, because of the increased number of contracts, there was an additional 47,853 hours (1,757,715 minus 1,709,862) of burden which offsets the net of additional and removed ICRs.

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Annual Cost to Federal Government: $778

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/09/2021

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