Information Collection

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

IC 43667 under ICR 201301-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 2014 MTMP - Fees Page Mockup 09172012.pdf	Other-MTMP - Fees Page Mockup
Appendix_C_CY 2014 MTMP - Resources Page Mockup 09172012.pdf	Other-MTMP - Resources Page Mockup
Appendix_C_CY 2014 MTMP - Review Tool Page Mockup 09172012.pdf	Other-Review Tool Page Mockup
Appendix_C_CY 2014 MTMP -Verification Page Mockup 09172012.pdf	Other-MTMP -Verification Page Mockup
Appendix_C_CY2014 Plan ADD File Record Layout 20120830.pdf	Other-Plan ADD File Record Layout
Appendix_C_CY2014 Plan Excluded Drugs Record Layout 20120830.pdf	Other-Plan Excluded Drugs Record Lay
Appendix_C_CY2014 Plan Gap Coverage File Layout 20120830.pdf	Other-Plan Gap Coverage File Layout
Appendix_C_CY2014 Plan Formulary Submission File Record Layout 20120830.pdf	Other-Plan Formulary Submission File
Appendix_C_CY2014 Plan Free First Fill File Record Layout 20120830.pdf	Other-Plan Free First Fill File Reco
Appendix_C_CY2014 Plan Home Infusion File Layout 120120830.pdf	Other-Plan Home Infusion File Layout
Appendix_C_CY2014 Plan Over The Counter File Record Layout 20120830.pdf	Other-Plan Over The Counter File Rec
Appendix_C_CY2014 Plan Prior Authorization Record Layout 20120830.pdf	Other-Plan Prior Authorization Recor
Appendix_C_CY2014 Plan Step Therapy Record Layout 20120830.pdf	Other-Plan Step Therapy Record Layou
Appendix_C_PBP 2014 screenshots_section Rx_2012_12_03.pdf	Other-Appendix_C_PBP 2014 screenshot
Appendix_C_PBP 2014 screenshots_section_b_2012_12_03.pdf	Other-Appendix_C_PBP 2014 screenshot
Appendix_C_PBP_2014 screenshots _section_d_2012_12_03.pdf	Other-Appendix_C_PBP_2014 screenshot
Appendix_C_PBP 2014 screenshots_section_c_2012_12_03.pdf	Other-Appendix_C_PBP 2014 screenshot
Appendix_C_PBP_2014 screenshots_section_a_2012_12_03.pdf	Other-Appendix_C_PBP_2014 screenshot
PRA2014 - ListofChanges_2012_12_11.docx List of Changes	IC Document
Appendix_D_ MMAFinalTitleIFederalRegister.pdf Appendix_D_ MMAFinalTitleIFederalRegister	IC Document
Appendix_D_ MMAFinalTitleIIFederalRegister.pdf Appendix_D_ MMAFinalTitleIIFederalRegister	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

CY2013 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 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

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	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

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: 641

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

Documents for IC

table that charts IC Documents
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.