OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Medicare Drug Coverage and Your Rights (CMS-10147)

OMB 0938-0975 ยท HHS/CMS.

OMB 0938-0975

Pursuant to 42 CFR 423.562(a)(3) and 423.128(b)(7)(iii), Part D plan sponsors must arrange with their network pharmacies to provide a printed copy of the standardized pharmacy notice to enrollees (beneficiaries) at the point of sale when an enrollee's prescription cannot be filled.

The latest form for Medicare Drug Coverage and Your Rights (CMS-10147) expires 2027-12-31 and is listed under ICR 202410-0938-020.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-10147 Medicare Drug Coverage and Your RightsForm
Form CMS-10147 Standardized Pharmacy NoticeForm
CMS-10147 - Supporting Statement A_.docxSupporting Statement A
CMS-10147 - Supporting Statement A_.docxSupporting Statement A
Crosswalk for CMS 10147.pdfSupplementary Document
Crosswalk for CMS 10147.pdf Supplementary Document
Standardized Pharmacy Notice Form
Standardized Pharmacy Notice Form
Standardized Pharmacy Notice Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202410-0938-020 Extension without change of a currently approved collection 2024-11-05
202103-0938-014 Reinstatement without change of a previously approved collection 2021-03-26 Approved without change
201804-0938-011 No material or nonsubstantive change to a currently approved collection 2018-04-17 Approved without change
201709-0938-002 Revision of a currently approved collection 2017-09-21 Approved with change
201408-0938-016 Extension without change of a currently approved collection 2014-08-29 Approved without change
201203-0938-003 No material or nonsubstantive change to a currently approved collection 2012-03-10 Approved without change
201109-0938-005 Revision of a currently approved collection 2011-09-21 Approved with change
200809-0938-001 Extension without change of a currently approved collection 2008-09-04 Approved without change
200603-0938-012 No material or nonsubstantive change to a currently approved collection 2006-03-22 Approved without change
200509-0938-015 New collection (Request for a new OMB Control Number) 2005-09-30 Approved with change