CY2013 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262

The Plan Benefit Package (PBP) and Formulary Submission for Advantage (MA) Plans and Prescription Drug Plans (PDPs)

OMB: 0938-0763

IC ID: 43667

Documents and Forms
Document Name
Document Type
Other-MTMP - Fees Page Mockup
Other-MTMP - Resources Page Mockup
Other-Review Tool Page Mockup
Other-MTMP -Verification Page Mockup
Other-Plan ADD File Record Layout
Other-Plan Excluded Drugs Record Lay
Other-Plan Gap Coverage File Layout
Other-Plan Formulary Submission File
Other-Plan Free First Fill File Reco
Other-Plan Home Infusion File Layout
Other-Plan Over The Counter File Rec
Other-Plan Prior Authorization Recor
Other-Plan Step Therapy Record Layou
Other-Appendix_C_PBP 2014 screenshot
Other-Appendix_C_PBP 2014 screenshot
Other-Appendix_C_PBP_2014 screenshot
Other-Appendix_C_PBP 2014 screenshot
Other-Appendix_C_PBP_2014 screenshot
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

CY2013 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 422.250 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 423.346 42 CFR 423.350

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Review Tool Page Mockup Appendix_C_CY 2014 MTMP - Review Tool Page Mockup 09172012.pdf Yes Yes Fillable Fileable
Other-MTMP -Verification Page Mockup Appendix_C_CY 2014 MTMP -Verification Page Mockup 09172012.pdf Yes Yes Fillable Fileable
Other-Plan ADD File Record Layout Appendix_C_CY2014 Plan ADD File Record Layout 20120830.pdf Yes Yes Fillable Fileable
Other-Plan Excluded Drugs Record Layout Appendix_C_CY2014 Plan Excluded Drugs Record Layout 20120830.pdf Yes Yes Fillable Fileable
Other-Plan Gap Coverage File Layout Appendix_C_CY2014 Plan Gap Coverage File Layout 20120830.pdf Yes Yes Fillable Fileable
Other-Plan Formulary Submission File Record Layout Appendix_C_CY2014 Plan Formulary Submission File Record Layout 20120830.pdf Yes Yes Fillable Fileable
Other-MTMP - Fees Page Mockup Appendix_C_CY 2014 MTMP - Fees Page Mockup 09172012.pdf Yes Yes Fillable Fileable
Other-MTMP - Resources Page Mockup Appendix_C_CY 2014 MTMP - Resources Page Mockup 09172012.pdf Yes Yes Fillable Fileable
Other-Plan Step Therapy Record Layout Appendix_C_CY2014 Plan Step Therapy Record Layout 20120830.pdf Yes Yes Fillable Fileable
Other-Appendix_C_PBP 2014 screenshots_section Appendix_C_PBP 2014 screenshots_section Rx_2012_12_03.pdf Yes Yes Fillable Fileable
Other-Appendix_C_PBP 2014 screenshots_section_b Appendix_C_PBP 2014 screenshots_section_b_2012_12_03.pdf Yes Yes Fillable Fileable
Other-Appendix_C_PBP_2014 screenshots _section_d Appendix_C_PBP_2014 screenshots _section_d_2012_12_03.pdf Yes Yes Fillable Fileable
Other-Appendix_C_PBP 2014 screenshots_section_c Appendix_C_PBP 2014 screenshots_section_c_2012_12_03.pdf Yes Yes Fillable Fileable
Other-Plan Free First Fill File Record Layout Appendix_C_CY2014 Plan Free First Fill File Record Layout 20120830.pdf Yes Yes Fillable Fileable
Other-Plan Home Infusion File Layout Appendix_C_CY2014 Plan Home Infusion File Layout 120120830.pdf Yes Yes Fillable Fileable
Other-Plan Over The Counter File Record Appendix_C_CY2014 Plan Over The Counter File Record Layout 20120830.pdf Yes Yes Fillable Fileable
Other-Plan Prior Authorization Record Layout Appendix_C_CY2014 Plan Prior Authorization Record Layout 20120830.pdf Yes Yes Fillable Fileable
Other-Appendix_C_PBP_2014 screenshots_section_a Appendix_C_PBP_2014 screenshots_section_a_2012_12_03.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

641 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 6,070 0 0 57 0 6,013
Annual IC Time Burden (Hours) 56,710 0 0 3,593 0 53,117
Annual IC Cost Burden (Dollars) 4,366,651 0 0 263,225 0 4,103,426

Title Document Date Uploaded
List of Changes PRA2014 - ListofChanges_2012_12_11.docx 01/18/2013
Appendix_D_ MMAFinalTitleIFederalRegister Appendix_D_ MMAFinalTitleIFederalRegister.pdf 01/18/2013
Appendix_D_ MMAFinalTitleIIFederalRegister Appendix_D_ MMAFinalTitleIIFederalRegister.pdf 01/18/2013
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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