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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 201102-0938-002 · OMB 0938-0763.

Documents and Forms
Document Name
Document Type
Other-Excluded_Drugs_Record_Layout
Other-Plan_Formulary_Submission_File
Other-Plan_Free_First_Fill_File_File
Other-Plan_Gap_Coverage_File_Layout
Other-Plan_Home_Infusion_File_Layout
Other-Plan_Over_The_Counter_File_Rec
Other-Plan_Prior_Authorization_Recor
Other-Step_Therapy_Record_Layout
Other-Formulary and Supplemental Rec
Other-screenshots_section_a
Other-screenshots_section_b
Other-screenshots_section_c
Other-screenshots_section_d
Other-screenshots_section_RX_Drugs
IC Document
Information Collection (IC) Details

View Information Collection (IC)

CY2011 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 423.343 42 CFR 423.346 42 CFR 423.350 42 CFR 422.250 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 422.252 42 CFR 422.254 42 CFR 423.329 42 CFR 423.272 42 CFR 423.336 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 423.265

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Excluded_Drugs_Record_Layout Appendix_C_CY2012_Plan_Excluded_Drugs_Record_Layout_09022010.pdf No No Fillable Fileable
Other-Plan_Formulary_Submission_File_Record_Layout Appendix_C_CY2012_Plan_Formulary_Submission_File_Record_Layout_09022010.pdf Yes Yes Fillable Printable
Other-Plan_Free_First_Fill_File_File_Layout Appendix_C_CY2012_Plan_Free_First_Fill_File_File_Layout_09022010.pdf Yes Yes Fillable Printable
Other-Plan_Gap_Coverage_File_Layout Appendix_C_CY2012_Plan_Gap_Coverage_File_Layout_09022010.pdf Yes Yes Fillable Printable
Other-Plan_Home_Infusion_File_Layout Appendix_C_CY2012_Plan_Home_Infusion_File_Layout_09022010.pdf Yes Yes Fillable Printable
Other-Plan_Over_The_Counter_File_Record_Layout Appendix_C_CY2012_Plan_Over_The_Counter_File_Record_Layout_09022010.pdf Yes Yes Fillable Printable
Other-Plan_Prior_Authorization_Record_Layout Appendix_C_CY2012_Plan_Prior_Authorization_Record_Layout_09022010.pdf Yes Yes Fillable Printable
Other-Step_Therapy_Record_Layout Appendix_C_CY2012_Step_Therapy_Record_Layout_09022010.pdf Yes Yes Fillable Printable
Other-Formulary and Supplemental Record Layouts Changes Appendix_C_CY 2012 Formulary and Supplemental Record Layouts Changes 091310.pdf Yes Yes Fillable Printable
Other-screenshots_section_a Appendix_C_PBP_2012_screenshots_section_a__2010_12_03.pdf Yes Yes Fillable Printable
Other-screenshots_section_b Appendix_C_PBP_2012_screenshots_section_b__2010_12_03.pdf Yes Yes Fillable Printable
Other-screenshots_section_c Appendix_C_PBP_2012_screenshots_section_c__2010_12_03.pdf Yes Yes Fillable Printable
Other-screenshots_section_d Appendix_C_PBP_2012_screenshots_section_d_2010_12_03.pdf Yes Yes Fillable Printable
Other-screenshots_section_RX_Drugs Appendix_C_PBP_2012_screenshots_section_RX_Drugs__2010_12_03.pdf Yes Yes Fillable Printable

Health Health Care Services

 

651 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 6,159 0 0 -719 0 6,878
Annual IC Time Burden (Hours) 54,407 0 0 36,387 0 18,020
Annual IC Cost Burden (Dollars) 4,189,358 0 0 3,018,035 0 1,171,323

Title Document Date Uploaded
Appendix_B_PRA 2012 List of Changes_12162010 Appendix_B_PRA 2012 List of Changes_12162010.pdf 01/13/2011
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.