Medicare Prescription Drug Benefit Program (Plans)

Medicare Prescription Drug Benefit Program (CMS-10141)

OMB: 0938-0964

IC ID: 187164

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0964 can be found here:

2023-02-22 - Revision of a currently approved collection

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 - Exhibit G - Example of a PartD-EOB- (all sections included) 30 day comment version.pdf Form and Instruction
CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections In Attachment 3h - Exhibit G - Example of a PartD-EOB- (all sections included) 30 day comment version.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Prescription Drug Benefit Program (Plans)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 942	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

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

Documents for IC

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.