Primary Manufacturer to Complete Drug Price Negotiation Program MTF DM Payment Elements Form

Medicare Transaction Facilitator for 2026 and 2027 under Sections 11001 and 11002 of the Inflation Reduction Act (IRA) (CMS-10912)

OMB:

IC ID: 274427

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Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
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Primary Manufacturer to Complete Drug Price Negotiation Program MTF DM Payment Elements Form
 
No New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10912 CMS-10912.MTF_ICR_ManufacturerPaymentElementsForm_clean CMS-10912.MTF_ICR_ManufacturerPaymentElementsForm_clean.docx Yes Yes Fillable Printable

Health Health Care Services

 

25 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved 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 25 0 25 0 0 0
Annual IC Time Burden (Hours) 71,500 0 71,500 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Track Change - MFRPaymentElementsForm 2025_03_10MTF_ICR_MFRPaymentElementsForm_trackchanges.pdf 03/19/2025
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