Information Collection

Medicare Prescription Drug Benefit Program (Plans)

IC 187164 under ICR 202302-0938-009 · OMB 0938-0964.

⚠️ Notice: This information collection may be referencing outdated material.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

2024-12-04 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
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 423.800 42 CFR 423.892 42 CFR 423.34 42 CFR 423.36 42 CFR 423.44 42 CFR 423.46 42 CFR 423.48 42 CFR 423.104 42 CFR 423.120 42 CFR 423.128 42 CFR 423.153 42 CFR 423.343 42 CFR 423.505 42 CFR 423.552 42 CFR 423.562 42 CFR 423.564 42 CFR 423.568 42 CFR 423.570 42 CFR 423.572 42 CFR 423.578

Information Collection Instruments:

table that charts list of 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: 990

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	690,557,096	27,674,048	662,883,048
Annual IC Time Burden (Hours)	24,330,233	-29,002,107	53,332,340
Annual IC Cost Burden (Dollars)	599,698,399	14,887,331	584,811,068

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.