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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10146 Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146) Form
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
CMS-10146 Spanish Notice of Denial of Prescription Drug Cvg Spanish Notice of Denial of Presc Drug Cvg_CMS10146_ Exp2026_508JM.pdf Form
CMS-10146 Spanish Notice of Denial of Prescription Drug Cvg Spanish Notice of Denial of Presc Drug Cvg_CMS10146_ Exp2026_508JM.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	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
Form	CMS-10146	Spanish Notice of Denial of Prescription Drug Cvg	Spanish Notice of Denial of Presc Drug Cvg_CMS10146_ Exp2026_508JM.pdf	Yes	No	Fillable Printable

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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,627,898	2,627,898
Annual IC Time Burden (Hours)	656,975	656,975
Annual IC Cost Burden (Dollars)	0	0

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.