Information Collection

Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)

IC 37928 under ICR 202212-0938-006 · OMB 0938-0976.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0976 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10146 Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)	Form
Denial Notice Instructions 2020 60 day v508.pdf	Instruction
Denial Notice Instructions 2020 60 day v508.pdf	Instruction
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co Denial Notice Exp 2026v508.pdf	Form
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co Denial Notice Exp 2026v508.pdf	Form

IC Title:

Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.580 42 CFR 423.582 42 CFR 423.568(c) 42 CFR 423.568(d)

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	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage	Denial Notice Exp 2026v508.pdf		Yes	No	Fillable Printable
Instruction			Denial Notice Instructions 2020 60 day v508.pdf		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 683

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,627,898	-259,968	2,887,866
Annual IC Time Burden (Hours)	656,975	-64,992	721,967
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.