Information Collection

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

IC 43667 under ICR 201401-0938-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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_CY2015 Plan ADD File Record Layout.pdf	Instruction
Appendix_C_CY2015 Plan Excluded Drugs Record Layout.pdf	Instruction
Appendix_C_CY2015 Plan Formulary Submission File Record Layout.pdf	Instruction
Appendix_C_CY2015 Plan Free First Fill File Record Layout.pdf	Instruction
Appendix_C_CY2015 Plan Gap Coverage File Layout.pdf	Instruction
Appendix_C_CY2015 Plan Home Infusion File Layout.pdf	Instruction
Appendix_C_CY2015 Plan Over The Counter File Record Layout.pdf	Instruction
Appendix_C_CY2015 Plan Prior Authorization Record Layout.pdf	Instruction
Appendix_C_CY2015 Plan Step Therapy Record Layout.pdf	Instruction
CMS-R-262 CY 2015 MTMP Screenshots Appendix_C_CY2015_MTMP_screenshots_PRA_09102013.pdf	Form
CMS-R-262 PBP 2015 Data Entry System (Rx screen shots) Appendix_C_PBP_2015_screenshots_section_ Rx_2013_12_19.pdf	Form
CMS-R-262 PBP 2015 Data Entry System (section A screen shots) Appendix_C_PBP_2015_screenshots_section_a_2013_11_20.pdf	Form
CMS-R-262 PBP 2015 Data Entry System (section B screen shots) Appendix_C_PBP_2015_screenshots_section_b_2013_12_19.pdf	Form
CMS-R-262 PBP 2015 Data Entry System (section C screen shots) Appendix_C_PBP_2015_screenshots_section_c_2013_12_19.pdf	Form
CMS-R-262 PBP 2015 Data Entry System (section D screen shots) Appendix_C_PBP_2015_screenshots_section_d_2013_11_20.pdf	Form
PRA 2015 - List of Chagnes_2013_12_20_V3.pdf Crosswalk	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	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Appendix_C_CY2015 Plan ADD File Record Layout.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2015 Plan Excluded Drugs Record Layout.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2015 Plan Formulary Submission File Record Layout.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2015 Plan Free First Fill File Record Layout.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2015 Plan Gap Coverage File Layout.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2015 Plan Home Infusion File Layout.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2015 Plan Over The Counter File Record Layout.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2015 Plan Prior Authorization Record Layout.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2015 Plan Step Therapy Record Layout.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	CY 2015 MTMP Screenshots	Appendix_C_CY2015_MTMP_screenshots_PRA_09102013.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	PBP 2015 Data Entry System (Rx screen shots)	Appendix_C_PBP_2015_screenshots_section_ Rx_2013_12_19.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	PBP 2015 Data Entry System (section A screen shots)	Appendix_C_PBP_2015_screenshots_section_a_2013_11_20.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	PBP 2015 Data Entry System (section B screen shots)	Appendix_C_PBP_2015_screenshots_section_b_2013_12_19.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	PBP 2015 Data Entry System (section C screen shots)	Appendix_C_PBP_2015_screenshots_section_c_2013_12_19.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	PBP 2015 Data Entry System (section D screen shots)	Appendix_C_PBP_2015_screenshots_section_d_2013_11_20.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: 652

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	6,169	99	6,070
Annual IC Time Burden (Hours)	57,477	767	56,710
Annual IC Cost Burden (Dollars)	0	-4,366,651	4,366,651

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	PRA 2015 - List of Chagnes_2013_12_20_V3.pdf	01/17/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.