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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 43667 under ICR 201401-0938-012 · OMB 0938-0763.

Documents and Forms
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Document Type
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form
Form
Form
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Form
Form
IC Document
Information Collection (IC) Details

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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
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

Health Health Care Services

 

652 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 6,169 0 0 99 0 6,070
Annual IC Time Burden (Hours) 57,477 0 0 767 0 56,710
Annual IC Cost Burden (Dollars) 0 0 0 -4,366,651 0 4,366,651

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.