Information Collection

CY2009 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262

IC 43667 under ICR 200801-0938-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
CMS-R-262 30 Day PRA PBP and Form.zip Other-Forms and Instructions
CMS-R-262 Appendix B - 2009 List of Changes_PBP and Formulary.doc Summary of Changes IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CY2009 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262	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 422.266 42 CFR 422.270 42 CFR 422.262 42 CFR 422.300 42 CFR 422.304 42 CFR 422.306 42 CFR 422.308 42 CFR 422.310 42 CFR 422.312 42 CFR 422.314 42 CFR 422.316 42 CFR 422.318 42 CFR 422.320 42 CFR 422.322 42 CFR 422.324 42 CFR 423.251 42 CFR 423.258 42 CFR 423.265 42 CFR 423.272 42 CFR 423.286 42 CFR 423.293 42 CFR 423.301 42 CFR 423.336 42 CFR 423.343 42 CFR 423.346 42 CFR 423.350 42 CFR 422.250 42 CFR 422.252 42 CFR 422.254 42 CFR 422.256 42 CFR 422.258 42 CFR 422.264 42 CFR 423.308 42 CFR 423.315 42 CFR 423.322 42 CFR 423.329

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Forms and Instructions			CMS-R-262 30 Day PRA PBP and Form.zip		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 475	Number of Respondents for Small Entity: 25

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,988	263	4,725
Annual IC Time Burden (Hours)	11,400	600	10,800
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Summary of Changes	CMS-R-262 Appendix B - 2009 List of Changes_PBP and Formulary.doc	01/03/2008

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