Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers

Part D Coordination of Benefits Data (CMS-10171)

Documents and Forms

Document Name Document Type
SPAP COB PRA 10171.pdf Instruction
Attachment 1. SPAP Attestation Submission.pdf Instruction

Information Collection (IC) Details

IC Title:	Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.464

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			SPAP COB PRA 10171.pdf		Yes	Yes	Fillable Printable
Instruction			Attachment 1. SPAP Attestation Submission.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 115,785	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	994,985,729	246,419,159	748,566,570
Annual IC Time Burden (Hours)	315,908	-623,060	938,968
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.