Information Collection

Beneficiary-Level Program Data Submission:

IC 266610 under ICR 202404-0938-007 · OMB 0938-1468.

Documents and Forms

Document Name Document Type
Form CMS-10887 Beneficiary-Level Program Data Submission: Form and Instruction
CMS-10887 Medicare Prescription Payment Plan example data layout PRA_MARx_OMB 0938_Appendix A_04022024.pdf Form and Instruction
CMS-10887 Medicare Prescription Payment Plan example data layout PRA_MARx_OMB 0938_Appendix A_04022024.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Beneficiary-Level Program Data Submission:	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.514

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10887	Medicare Prescription Payment Plan example data layout	PRA_MARx_OMB 0938_Appendix A_04022024.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Advantage Prescription Drug (MARx) System	FR Citation: 70 FR 60530

Number of Respondents: 856	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,200,000	3,200,000
Annual IC Time Burden (Hours)	38	38
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.