OMB.report

Federal forms, ICRs, and supporting documents

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.

Documents and Forms
Document Name
Document Type
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Other-Screen
Form and Instruction
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form and Instruction
Form
Form
Form
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

The Plan Benefit Package (PBP) and Formulary Submission for Advantage (MA) Plans and Prescription Drug Plans (PDPs)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 423.Subpart G 42 CFR 422.Subpart F 42 CFR 422.Subpart G 42 CFR 423.Subpart F

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

450 20
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,725 0 0 210 0 4,515
Annual IC Time Burden (Hours) 10,800 0 0 481 0 10,319
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.