Information Collection

CY2011 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262

IC 43667 under ICR 201001-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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_CY 2011 Plan Excluded Drugs Record Layout 091109.pdf	Other-Record Layout
Appendix_C_CY 2011 Plan Formulary File Record Layout 091109.pdf	Other-File Record Layout
Appendix_C_CY 2011 Plan Free First Fill File Record Layout 091109.pdf	Other-File Record Layout
Appendix_C_CY 2011 Plan Gap Coverage File Record Layout 091109.pdf	Other-File Record Layout
Appendix_C_CY 2011 Plan Home Infusion File Record Layout 091109.pdf	Other-File Record Layout
5-Appendix_C_CY 2011 Plan Over the Counter Record Layout 03012010.pdf	Other-File Record Layout
Appendix_C_CY 2011 Plan Prior Authorization Record Layout 091109.pdf	Other-File Record Layout
Appendix_C_CY 2011 Plan Step Therapy Record Layout 091109.pdf	Other-Record Layout
Appendix_C_MTMP screenshots_121409_final.pdf	Other-screenshots
Appendix_C_PBP_2011_screenshots_sec_a_121709_final.pdf	Other-screenshots
Appendix_C_PBP_2011_screenshots_sec_b_121709_final.pdf	Other-screenshots
Appendix_C_PBP_2011_screenshots_sec_c_121709_final.pdf	Other-screenshots
Appendix_C_PBP_2011_screenshots_sec_d_121709_final.pdf	Other-screenshots
Appendix_C_PBP_2011_screenshots_sec_d_121709_final.pdf	Other-screenshots
Appendix_B_PBP_2011_List_of_Changes_12142009_final.pdf Appendix_B_PBP_2011_List_of_Changes_12142009_final	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

CY2011 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 423.346 42 CFR 422.252 42 CFR 422.254 42 CFR 422.256 42 CFR 422.258 42 CFR 422.262 42 CFR 422.264 42 CFR 422.266 42 CFR 422.270 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 423.308 42 CFR 423.315 42 CFR 423.322 42 CFR 423.329 42 CFR 423.336 42 CFR 423.343 42 CFR 423.350 42 CFR 422.250

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Record Layout	Appendix_C_CY 2011 Plan Excluded Drugs Record Layout 091109.pdf	Yes	Yes	Printable Only
Other-File Record Layout	Appendix_C_CY 2011 Plan Formulary File Record Layout 091109.pdf	Yes	Yes	Printable Only
Other-File Record Layout	Appendix_C_CY 2011 Plan Free First Fill File Record Layout 091109.pdf	Yes	Yes	Printable Only
Other-File Record Layout	Appendix_C_CY 2011 Plan Gap Coverage File Record Layout 091109.pdf	Yes	Yes	Printable Only
Other-File Record Layout	Appendix_C_CY 2011 Plan Home Infusion File Record Layout 091109.pdf	Yes	Yes	Printable Only
Other-File Record Layout	Appendix_C_CY 2011 Plan Prior Authorization Record Layout 091109.pdf	Yes	Yes	Printable Only
Other-Record Layout	Appendix_C_CY 2011 Plan Step Therapy Record Layout 091109.pdf	Yes	Yes	Printable Only
Other-screenshots	Appendix_C_MTMP screenshots_121409_final.pdf	Yes	Yes	Printable Only
Other-screenshots	Appendix_C_PBP_2011_screenshots_sec_a_121709_final.pdf	Yes	Yes	Printable Only
Other-screenshots	Appendix_C_PBP_2011_screenshots_sec_b_121709_final.pdf	Yes	Yes	Printable Only
Other-screenshots	Appendix_C_PBP_2011_screenshots_sec_c_121709_final.pdf	Yes	Yes	Printable Only
Other-screenshots	Appendix_C_PBP_2011_screenshots_sec_d_121709_final.pdf	Yes	Yes	Printable Only
Other-screenshots	Appendix_C_PBP_2011_screenshots_sec_d_121709_final.pdf	Yes	Yes	Printable Only
Other-File Record Layout	5-Appendix_C_CY 2011 Plan Over the Counter Record Layout 03012010.pdf	Yes	Yes	Printable 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: 655

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 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,878	1,890	4,988
Annual IC Time Burden (Hours)	18,020	5,907	12,113
Annual IC Cost Burden (Dollars)	1,171,323	1,171,323	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix_B_PBP_2011_List_of_Changes_12142009_final	Appendix_B_PBP_2011_List_of_Changes_12142009_final.pdf	01/06/2010

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