Medicare Prescription Drug Benefit Program (Plans)

Medicare Prescription Drug Benefit Program (CMS-10141)

OMB: 0938-0964

IC ID: 187164

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Medicare Prescription Drug Benefit Program (Plans)
 
No Modified
 
Mandatory
 
42 CFR 423

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Attachment 1a. Instructions for Drug Management Program Notices.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Initial Notice Sent to Potentially At-Risk Beneficiaries Attachment 1b. Initial DMP Notice.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Second Notice Sent to Beneficiary Designating At-Risk Status Attachment 1c. Second DMP Notice.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Alternate Second Notice Sent to Beneficiary Not Considered At-Risk Attachment 1d. Alternate 2nd Notice.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Model Prescriber Inquiry Letter Attachment 1e. Model Prescriber Inquiry Letter.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 Model Sponsor Information Transfer Memo Attachment 1f. Model Sponsor Information Transfer Memo.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 3a - 2022 Model Part D Explanation of Benefits (All Sections Included) Attachment 3a. CY 2022 EOB.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 3b - Exhibit A: Example Cover Page of the Model Part D EOB Attachment 3b. CY 2022 EOB Exhibit A.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 3c - Exhibit B: Examples of Section 1 (the List of Prescriptions) Attachment 3c. CY 2022 EOB Exhibit B.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 3d - Exhibit C: Example of Section 2 (Drug Payment Stages) Attachment 3d. CY 2022 EOB Exhibit C.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 3e - Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs) Attachment 3e. CY 2022 EOB Exhibit D.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 3f - Exhibit E: Example of Section 4 (Changes to the Formulary) Attachment 3f. CY 2022 EOB Exhibit E.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 3g - Exhibit F: Example of Sections 5 and 6 (Information for Reference) Attachment 3g. CY 2022 EOB Exhibit F.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections Included) Attachment 3h - Exhibit G - Example of a PartD-EOB- (all sections included) 30 day comment version.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

942 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 662,883,048 0 -102 0 0 662,883,150
Annual IC Time Burden (Hours) 53,332,340 0 47,204,136 0 0 6,128,204
Annual IC Cost Burden (Dollars) 584,811,068 0 578,558,395 0 0 6,252,673

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