Part D Coordination of Benefits Data (CMS-10171)

OMB 0938-0978

This information is necessary to assist with coordination of prescription drug benefits provided to the Medicare beneficary at the pharmacy.

The latest form for Part D Coordination of Benefits Data (CMS-10171) expires 2020-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
CMS-10171 - Supporting Statement Clean v2.docx Supporting Statement A
Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers Instruction

All Historical Document Collections

202011-0938-014	Reinstatement without change of a previously approved collection	2020-12-09
201702-0938-016 Approved with change	Revision of a currently approved collection	2017-02-27
201311-0938-015 Approved without change	Revision of a currently approved collection	2013-11-14
201008-0938-009 Approved without change	Revision of a currently approved collection	2010-08-17
200906-0938-015 Approved with change	Revision of a currently approved collection	2009-06-25
200604-0938-001 Approved without change	Extension without change of a currently approved collection	2006-04-11
200601-0938-012 Approved without change	No material or nonsubstantive change to a currently approved collection	2006-01-20
200510-0938-004 Approved without change	New collection (Request for a new OMB Control Number)	2005-10-14