Part D Drug Management Program

Part D Drug Management Program (CMS-10874)

Documents and Forms

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
Crosswalk - All Revised Instruments.pdf Crosswalk: All Instruments IC Document
Crosswalk - All Revised Instruments.pdf Crosswalk: All Instruments IC Document

Information Collection (IC) Details

IC Title:	Part D Drug Management Program	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection 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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	62,248	62,248
Annual IC Time Burden (Hours)	152,585	152,585
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk: All Instruments	Crosswalk - All Revised Instruments.pdf	08/08/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.