Medicare Prescription Drug Benefit Program (Plans)

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

OMB: 0938-0964

IC ID: 187164

Documents and Forms

Document Name Document Type
Attachment 1a. Instructions for Drug Management Program Notices.pdf Instruction
Attachment 1a. Instructions for Drug Management Program Notices.pdf Instruction
CMS-10141 Initial Notice Sent to Potentially At-Risk Beneficiaries Attachment 1b. Initial DMP Notice.pdf Form and Instruction
CMS-10141 Initial Notice Sent to Potentially At-Risk Beneficiaries Attachment 1b. Initial DMP Notice.pdf Form and Instruction
CMS-10141 Second Notice Sent to Beneficiary Designating At-Risk St Attachment 1c. Second DMP Notice.pdf Form and Instruction
CMS-10141 Second Notice Sent to Beneficiary Designating At-Risk St Attachment 1c. Second DMP Notice.pdf Form and Instruction
CMS-10141 Alternate Second Notice Sent to Beneficiary Not Consider Attachment 1d. Alternate 2nd Notice.pdf Form and Instruction
CMS-10141 Alternate Second Notice Sent to Beneficiary Not Consider Attachment 1d. Alternate 2nd Notice.pdf Form and Instruction
CMS-10141 Model Prescriber Inquiry Letter Attachment 1e. Model Prescriber Inquiry Letter.pdf Form and Instruction
CMS-10141 Model Prescriber Inquiry Letter Attachment 1e. Model Prescriber Inquiry Letter.pdf Form and Instruction
CMS-10141 Model Sponsor Information Transfer Memo Attachment 1f. Model Sponsor Information Transfer Memo.pdf Form and Instruction
CMS-10141 Model Sponsor Information Transfer Memo Attachment 1f. Model Sponsor Information Transfer Memo.pdf Form and Instruction
CMS-10141 3a - 2022 Model Part D Explanation of Benefits (All Sect Attachment 3a. CY 2022 EOB.pdf Form and Instruction
CMS-10141 3a - 2022 Model Part D Explanation of Benefits (All Sect Attachment 3a. CY 2022 EOB.pdf Form and Instruction
CMS-10141 3b - Exhibit A: Example Cover Page of the Model Part D E Attachment 3b. CY 2022 EOB Exhibit A.pdf Form and Instruction
CMS-10141 3b - Exhibit A: Example Cover Page of the Model Part D E Attachment 3b. CY 2022 EOB Exhibit A.pdf Form and Instruction
CMS-10141 3c - Exhibit B: Examples of Section 1 (the List of Presc Attachment 3c. CY 2022 EOB Exhibit B.pdf Form and Instruction
CMS-10141 3c - Exhibit B: Examples of Section 1 (the List of Presc Attachment 3c. CY 2022 EOB Exhibit B.pdf Form and Instruction
CMS-10141 3d - Exhibit C: Example of Section 2 (Drug Payment Stage Attachment 3d. CY 2022 EOB Exhibit C.pdf Form and Instruction
CMS-10141 3d - Exhibit C: Example of Section 2 (Drug Payment Stage Attachment 3d. CY 2022 EOB Exhibit C.pdf Form and Instruction
CMS-10141 3e - Exhibit D: Example of Section 3 (Amounts and Defini Attachment 3e. CY 2022 EOB Exhibit D.pdf Form and Instruction
CMS-10141 3e - Exhibit D: Example of Section 3 (Amounts and Defini Attachment 3e. CY 2022 EOB Exhibit D.pdf Form and Instruction
CMS-10141 3f - Exhibit E: Example of Section 4 (Changes to the For Attachment 3f. CY 2022 EOB Exhibit E.pdf Form and Instruction
CMS-10141 3f - Exhibit E: Example of Section 4 (Changes to the For Attachment 3f. CY 2022 EOB Exhibit E.pdf Form and Instruction
CMS-10141 3g - Exhibit F: Example of Sections 5 and 6 (Information Attachment 3g. CY 2022 EOB Exhibit F.pdf Form and Instruction
CMS-10141 3g - Exhibit F: Example of Sections 5 and 6 (Information Attachment 3g. CY 2022 EOB Exhibit F.pdf Form and Instruction
CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections In Attachment 3h. CY 2022 EOB Exhibit G.pdf Form and Instruction
CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections In Attachment 3h. CY 2022 EOB Exhibit G.pdf Form and Instruction