Information Collection

The Plan Benefit Package (PBP) and Formulary Submission for Advantage (MA) Plans and Prescription Drug Plans (PDPs)

IC 43667 under ICR 200703-0938-005 · OMB 0938-0763.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0763 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix C - PBP_2008_screenshots_sec_b10.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_b11.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_b12.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_b13.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_b14.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_b15.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_b16.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_b17.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_b18.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_b20.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_c_CSR.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_c_OON.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_c_POS.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_c_VT_Foreign.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_c_VT_US.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_d_optsupp_general.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_d_optsupp_OON.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_d_optsupp_stepup.doc	Other-Screen
Appendix C - PBP_2008_screenshots_sec_d_plan_costs.doc	Other-Screen
CMS-R-262 CY 2008 Formulary File Record Layout CMS-R-262 Appendix C - CY2008 Form File Record Layout_12222006.doc	Form and Instruction
CMS-R-262 SECTION B - 6 - HOME HEALTH - BASE 1 SCREEN Appendix C - PBP_2008_screenshots_sec_b6.doc	Form
CMS-R-262 SECTION B - 7A - PRIMARY CARE PHYSICIAN - BASE 1 SCREEN Appendix C - PBP_2008_screenshots_sec_b7.doc	Form
CMS-R-262 SECTION B - 8A - OUTPATIENT DIAGNOSTIC PROCEDURES AND TE Appendix C - PBP_2008_screenshots_sec_b8.doc	Form
CMS-R-262 PRESCRIPTION DRUGS SECTION-ACTUARIALLY EQUIVALENT-DEDUCT Appendix_C_-_PBP_2008_screenshots_Medicare_Rx_Drugs_ae.doc	Form
CMS-R-262 Medicare Prescription Drugs Section-Alternative Appendix C - PBP_2008_screenshots_Medicare_Rx_Drugs_alt.doc	Form
CMS-R-262 Medicare Prescription Drugs Section-Defined Stan Appendix C - PBP_2008_screenshots_Medicare_Rx_Drugs_ds.doc	Form
CMS-R-262 Medicare Prescription Druges Section-Part D-GE Appendix C - PBP_2008_screenshots_Medicare_Rx_Drugs_general.doc	Form
CMS-R-262 Section A - A-1 Screen Appendix C - PBP_2008_screenshots_sec_a.doc	Form
CMS-R-262 Section B-1A-Inpartient Hospital Acute-Base Appendix C - PBP_2008_screenshots_sec_b1.doc	Form
CMS-R-262 Section B-2-SNF-Base 1 Screen Appendix C - PBP_2008_screenshots_sec_b2.doc	Form and Instruction
CMS-R-262 Section B-3-CORF-Base 1 Screen Appendix C - PBP_2008_screenshots_sec_b3.doc	Form
CMS-R-262 Section B-4A-Emergency Care-Base 1 Screen Appendix C - PBP_2008_screenshots_sec_b4.doc	Form
CMS-R-262 Section B-5-Partial Hospitalization-Base 1 Appendix C - PBP_2008_screenshots_sec_b5.doc	Form
CMS-R-262 Section B-9A-Outpatient Hospital-Base 1 Scre Appendix C - PBP_2008_screenshots_sec_b9.doc	Form
CMS-R-262 Appendix B - PBP-Formulary CY2008 List of Changes.DOC List of changes	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

The Plan Benefit Package (PBP) and Formulary Submission for Advantage (MA) Plans and Prescription Drug Plans (PDPs)

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.Subpart G 42 CFR 422.Subpart F 42 CFR 422.Subpart G 42 CFR 423.Subpart F

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screen			Appendix C - PBP_2008_screenshots_sec_c_OON.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_c_POS.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_c_VT_Foreign.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_c_VT_US.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_d_optsupp_general.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-R-262	CY 2008 Formulary File Record Layout	CMS-R-262 Appendix C - CY2008 Form File Record Layout_12222006.doc	Yes	Yes	Paper Only
Form	CMS-R-262	SECTION B - 6 - HOME HEALTH - BASE 1 SCREEN	Appendix C - PBP_2008_screenshots_sec_b6.doc	Yes	Yes	Paper Only
Form	CMS-R-262	SECTION B - 7A - PRIMARY CARE PHYSICIAN - BASE 1 SCREEN	Appendix C - PBP_2008_screenshots_sec_b7.doc	Yes	Yes	Paper Only
Form	CMS-R-262	SECTION B - 8A - OUTPATIENT DIAGNOSTIC PROCEDURES AND TESTS AND LAB SERVICES - BASE 1 SCREEN	Appendix C - PBP_2008_screenshots_sec_b8.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_b10.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_b11.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_b12.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_b13.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_b14.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_b15.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_b16.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_b17.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_b18.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_b20.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_c_CSR.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_d_optsupp_OON.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_d_optsupp_stepup.doc	Yes	Yes	Paper Only
Other-Screen			Appendix C - PBP_2008_screenshots_sec_d_plan_costs.doc	Yes	Yes	Paper Only
Form	CMS-R-262	PRESCRIPTION DRUGS SECTION-ACTUARIALLY EQUIVALENT-DEDUCTIBLE AND PRE-ICL SCREEN	Appendix_C_-_PBP_2008_screenshots_Medicare_Rx_Drugs_ae.doc	Yes	Yes	Paper Only
Form	CMS-R-262	Medicare Prescription Drugs Section-Alternative	Appendix C - PBP_2008_screenshots_Medicare_Rx_Drugs_alt.doc	Yes	Yes	Paper Only
Form	CMS-R-262	Medicare Prescription Drugs Section-Defined Stan	Appendix C - PBP_2008_screenshots_Medicare_Rx_Drugs_ds.doc	Yes	Yes	Paper Only
Form	CMS-R-262	Medicare Prescription Druges Section-Part D-GE	Appendix C - PBP_2008_screenshots_Medicare_Rx_Drugs_general.doc	Yes	Yes	Paper Only
Form	CMS-R-262	Section A - A-1 Screen	Appendix C - PBP_2008_screenshots_sec_a.doc	Yes	Yes	Paper Only
Form	CMS-R-262	Section B-1A-Inpartient Hospital Acute-Base	Appendix C - PBP_2008_screenshots_sec_b1.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-R-262	Section B-2-SNF-Base 1 Screen	Appendix C - PBP_2008_screenshots_sec_b2.doc	Yes	Yes	Paper Only
Form	CMS-R-262	Section B-3-CORF-Base 1 Screen	Appendix C - PBP_2008_screenshots_sec_b3.doc	Yes	Yes	Paper Only
Form	CMS-R-262	Section B-4A-Emergency Care-Base 1 Screen	Appendix C - PBP_2008_screenshots_sec_b4.doc	Yes	Yes	Paper Only
Form	CMS-R-262	Section B-5-Partial Hospitalization-Base 1	Appendix C - PBP_2008_screenshots_sec_b5.doc	Yes	Yes	Paper Only
Form	CMS-R-262	Section B-9A-Outpatient Hospital-Base 1 Scre	Appendix C - PBP_2008_screenshots_sec_b9.doc	Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 450

Number of Respondents for Small Entity: 20

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,725	210	4,515
Annual IC Time Burden (Hours)	10,800	481	10,319
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
List of changes	CMS-R-262 Appendix B - PBP-Formulary CY2008 List of Changes.DOC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.