Information Collection

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

IC 43667 under ICR 201102-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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_CY2012_Plan_Excluded_Drugs_Record_Layout_09022010.pdf	Other-Excluded_Drugs_Record_Layout
Appendix_C_CY2012_Plan_Formulary_Submission_File_Record_Layout_09022010.pdf	Other-Plan_Formulary_Submission_File
Appendix_C_CY2012_Plan_Free_First_Fill_File_File_Layout_09022010.pdf	Other-Plan_Free_First_Fill_File_File
Appendix_C_CY2012_Plan_Gap_Coverage_File_Layout_09022010.pdf	Other-Plan_Gap_Coverage_File_Layout
Appendix_C_CY2012_Plan_Home_Infusion_File_Layout_09022010.pdf	Other-Plan_Home_Infusion_File_Layout
Appendix_C_CY2012_Plan_Over_The_Counter_File_Record_Layout_09022010.pdf	Other-Plan_Over_The_Counter_File_Rec
Appendix_C_CY2012_Plan_Prior_Authorization_Record_Layout_09022010.pdf	Other-Plan_Prior_Authorization_Recor
Appendix_C_CY2012_Step_Therapy_Record_Layout_09022010.pdf	Other-Step_Therapy_Record_Layout
Appendix_C_CY 2012 Formulary and Supplemental Record Layouts Changes 091310.pdf	Other-Formulary and Supplemental Rec
Appendix_C_PBP_2012_screenshots_section_a__2010_12_03.pdf	Other-screenshots_section_a
Appendix_C_PBP_2012_screenshots_section_b__2010_12_03.pdf	Other-screenshots_section_b
Appendix_C_PBP_2012_screenshots_section_c__2010_12_03.pdf	Other-screenshots_section_c
Appendix_C_PBP_2012_screenshots_section_d_2010_12_03.pdf	Other-screenshots_section_d
Appendix_C_PBP_2012_screenshots_section_RX_Drugs__2010_12_03.pdf	Other-screenshots_section_RX_Drugs
Appendix_B_PRA 2012 List of Changes_12162010.pdf Appendix_B_PRA 2012 List of Changes_12162010	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 423.343 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

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	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

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: 651

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

Documents for IC

table that charts IC Documents
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.