Information Collection

Part D Drug Management Program

IC 264405 under ICR 202312-0938-003 · OMB 0938-1465.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1465 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10874 Part D Drug Management Program	Form
Instructions for Drug Management Program Notices.pdf	Instruction
Instructions for Drug Management Program Notices.pdf	Instruction
CMS-10874 Initial Notice Initial DMP Notice.pdf	Form
CMS-10874 Initial Notice Initial DMP Notice.pdf	Form
CMS-10874 Second Notice Second DMP Notice.pdf	Form
CMS-10874 Second Notice Second DMP Notice.pdf	Form
CMS-10874 Alternate Second Notice Alternate Second DMP Notice.pdf	Form
CMS-10874 Alternate Second Notice Alternate Second DMP Notice.pdf	Form
CMS-10874 Model Prescriber Inquiry Letter Model Prescriber Inquiry Letter.pdf	Form
CMS-10874 Model Prescriber Inquiry Letter Model Prescriber Inquiry Letter.pdf	Form
CMS-10874 Model Sponsor Information Transfer Memorandum Model Sponsor Information Transfer Memo.pdf	Form
CMS-10874 Model Sponsor Information Transfer Memorandum Model Sponsor Information Transfer Memo.pdf	Form

IC Title:

Part D Drug Management Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

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
Form	CMS-10874	Initial Notice	Initial DMP Notice.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10874	Second Notice	Second DMP Notice.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10874	Alternate Second Notice	Alternate Second DMP Notice.pdf	Yes	Yes	Fillable Fileable
Instruction			Instructions for Drug Management Program Notices.pdf	Yes	No	Printable Only
Form	CMS-10874	Model Prescriber Inquiry Letter	Model Prescriber Inquiry Letter.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10874	Model Sponsor Information Transfer Memorandum	Model Sponsor Information Transfer Memo.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Advantage Prescription Drug System (MARx) System

FR Citation: 83 FR 6591

Number of Respondents: 319

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	62,256	62,256
Annual IC Time Burden (Hours)	152,593	152,593
Annual IC Cost Burden (Dollars)	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.