Medicare Prescription Drug Benefit Program (Plans)

Medicare Prescription Drug Benefit Program - IRASA (CMS-10141)

OMB: 0938-0964

IC ID: 187164

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Medicare Prescription Drug Benefit Program (Plans)
 
No Modified
 
Mandatory
 
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

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10141 Part C and D Model Precluded Provider Letter Part C and D Model Precluded Provider Letter.docx 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.docx 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.docx 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.docx 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.docx 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.docx 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.docx 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.docx 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 Part D-EOB- (all sections included).docx Yes Yes Fillable Fileable

Health Health Care Services

 

966 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 81,767,836 0 -608,789,260 0 0 690,557,096
Annual IC Time Burden (Hours) 24,221,864 0 -108,369 0 0 24,330,233
Annual IC Cost Burden (Dollars) 593,251,773 0 -6,446,626 0 0 599,698,399

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