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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 43667 under ICR 201001-0938-002 · OMB 0938-0763.

Documents and Forms
Document Name
Document Type
Other-Record Layout
Other-File Record Layout
Other-File Record Layout
Other-File Record Layout
Other-File Record Layout
Other-File Record Layout
Other-File Record Layout
Other-Record Layout
Other-screenshots
Other-screenshots
Other-screenshots
Other-screenshots
Other-screenshots
Other-screenshots
IC Document
Information Collection (IC) Details

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CY2011 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262
 
No Modified
 
Required to Obtain or Retain Benefits
 
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

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

655 25
   
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 6,878 0 0 1,890 0 4,988
Annual IC Time Burden (Hours) 18,020 0 0 5,907 0 12,113
Annual IC Cost Burden (Dollars) 1,171,323 0 0 1,171,323 0 0

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.