Information Collection

Medicare Prescription Drug Benefit Program (Plans)

IC 187164 under ICR 202412-0938-003 · OMB 0938-0964.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10141 Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction
Form CMS-10141 Part C and D Model Precluded Provider Letter Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction
Form CMS-10141 3a - 2022 Model Part D Explanation of Benefits (All Sections Included) Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction
Form CMS-10141 3b - Exhibit A: Example Cover Page of the Model Part D EOB Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction
Form CMS-10141 3c - Exhibit B: Examples of Section 1 (the List of Prescriptions) Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction
Form CMS-10141 3d - Exhibit C: Example of Section 2 (Drug Payment Stages) Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction
Form CMS-10141 3e - Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs) Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction
Form CMS-10141 3f - Exhibit E: Example of Section 4 (Changes to the Formulary) Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction
Form CMS-10141 3g - Exhibit F: Example of Sections 5 and 6 (Information for Reference) Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction
Form CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections Included) Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction
CMS-10141 Part C and D Model Precluded Provider Letter Part C and D Model Precluded Provider Letter.docx	Form and Instruction
CMS-10141 Part C and D Model Precluded Provider Letter Part C and D Model Precluded Provider Letter.docx	Form and Instruction
CMS-10141 3a - 2022 Model Part D Explanation of Benefits (All Sect Attachment 3a. CY 2022 EOB.pdf.docx	Form and Instruction
CMS-10141 3a - 2022 Model Part D Explanation of Benefits (All Sect Attachment 3a. CY 2022 EOB.pdf.docx	Form and Instruction
CMS-10141 3b - Exhibit A: Example Cover Page of the Model Part D E Attachment 3b. CY 2022 EOB Exhibit A.pdf.docx	Form and Instruction
CMS-10141 3b - Exhibit A: Example Cover Page of the Model Part D E Attachment 3b. CY 2022 EOB Exhibit A.pdf.docx	Form and Instruction
CMS-10141 3c - Exhibit B: Examples of Section 1 (the List of Presc Attachment 3c. CY 2022 EOB Exhibit B.pdf.docx	Form and Instruction
CMS-10141 3c - Exhibit B: Examples of Section 1 (the List of Presc Attachment 3c. CY 2022 EOB Exhibit B.pdf.docx	Form and Instruction
CMS-10141 3d - Exhibit C: Example of Section 2 (Drug Payment Stage Attachment 3d. CY 2022 EOB Exhibit C.docx	Form and Instruction
CMS-10141 3d - Exhibit C: Example of Section 2 (Drug Payment Stage Attachment 3d. CY 2022 EOB Exhibit C.docx	Form and Instruction
CMS-10141 3e - Exhibit D: Example of Section 3 (Amounts and Defini Attachment 3e. CY 2022 EOB Exhibit D.docx	Form and Instruction
CMS-10141 3e - Exhibit D: Example of Section 3 (Amounts and Defini Attachment 3e. CY 2022 EOB Exhibit D.docx	Form and Instruction
CMS-10141 3f - Exhibit E: Example of Section 4 (Changes to the For Attachment 3f. CY 2022 EOB Exhibit E.docx	Form and Instruction
CMS-10141 3f - Exhibit E: Example of Section 4 (Changes to the For Attachment 3f. CY 2022 EOB Exhibit E.docx	Form and Instruction
CMS-10141 3g - Exhibit F: Example of Sections 5 and 6 (Information Attachment 3g. CY 2022 EOB Exhibit F.docx	Form and Instruction
CMS-10141 3g - Exhibit F: Example of Sections 5 and 6 (Information Attachment 3g. CY 2022 EOB Exhibit F.docx	Form and Instruction
CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections In Attachment 3h - Exhibit G - Example of a Part D-EOB- (all sections included).docx	Form and Instruction
CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections In Attachment 3h - Exhibit G - Example of a Part D-EOB- (all sections included).docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Prescription Drug Benefit Program (Plans)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.564 42 CFR 423.568 42 CFR 423.562 42 CFR 423.570 42 CFR 423.572 42 CFR 423.578 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 423.153 42 CFR 423.343 42 CFR 423.120 42 CFR 423.128 42 CFR 423.505 42 CFR 423.552

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10141	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10141	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 966

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	81,767,836	-608,789,260	690,557,096
Annual IC Time Burden (Hours)	24,221,864	-108,369	24,330,233
Annual IC Cost Burden (Dollars)	593,251,773	-6,446,626	599,698,399

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.

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