Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0976 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10146 Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146) Form
Instructions for Denial Notice Exp 2027_508.pdf Instruction
Instructions for Denial Notice Exp 2027_508.pdf Instruction
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co English Notice of Denial of Presc Drug Cvg_CMS10146_ Exp2027_v508.pdf Form
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co English Notice of Denial of Presc Drug Cvg_CMS10146_ Exp2027_v508.pdf Form
CMS-10146 Spanish Notice of Denial of Prescription Drug Cvg Spanish Notice of Denial of Presc Drug Cvg_CMS10146_ Exp2027_v508.pdf Form
CMS-10146 Spanish Notice of Denial of Prescription Drug Cvg Spanish Notice of Denial of Presc Drug Cvg_CMS10146_ Exp2027_v508.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.582 42 CFR 423.568(c) 42 CFR 423.568(d) 42 CFR 423.580

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage	English Notice of Denial of Presc Drug Cvg_CMS10146_ Exp2027_v508.pdf	Yes	No	Fillable Printable
Instruction			Instructions for Denial Notice Exp 2027_508.pdf	No		Printable Only
Form	CMS-10146	Spanish Notice of Denial of Prescription Drug Cvg	Spanish Notice of Denial of Presc Drug Cvg_CMS10146_ Exp2027_v508.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 743	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,631,728	3,830	2,627,898
Annual IC Time Burden (Hours)	657,932	957	656,975
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.