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Federal forms, ICRs, and supporting documents

Information Collection

CY2016 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

IC 43667 under ICR 201412-0938-008 · OMB 0938-0763.

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

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CY2016 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)
 
No Modified
 
Required to Obtain or Retain Benefits
 
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 423.315 42 CFR 423.322 42 CFR 423.329 42 CFR 423.308 42 CFR 423.336 42 CFR 423.343 42 CFR 423.346 42 CFR 423.350 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 422.306 42 CFR 422.304 42 CFR 422.308 42 CFR 422.310

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Appendix_C_CY2016 Plan Gap Coverage File Layout.pdf Yes Yes Printable Only
Instruction Appendix_C_CY2016 Plan Home Infusion File Layout.pdf Yes Yes Printable Only
Instruction Appendix_C_CY2016 Plan Over The Counter File Record Layout.pdf Yes Yes Printable Only
Instruction Appendix_C_CY2016 Plan Prior Authorization Record Layout.pdf Yes Yes Printable Only
Instruction Appendix_C_CY2016 Plan Step Therapy Record Layout.pdf Yes Yes Printable Only
Form and Instruction CMS-R-262 CY 2016 MTMP – Fees Page Mockups Appendix_C_MTMP_Fees Page Mockup 09082014.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2016 PBP Data Entry System Screens (section A) Appendix_C_PBP_2016_ screenshots_section_a_2014_12_05.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2016 PBP Data Entry System Screens (section B) Appendix_C_PBP_2016_ screenshots_section_b_2014_12_05.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2016 PBP Data Entry System Screens (section C) Appendix_C_PBP_2016_ screenshots_section_c_2014_12_05.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2016 PBP Data Entry System Screens (section D) Appendix_C_PBP_2016_ screenshots_section_d_2014_12_04.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2016 PBP Data Entry System Screens (section Rx) Appendix_C_PBP_2016_ screenshots_section_Rx_2014_12_05.pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2016 Plan ADD File Record Layout.pdf Yes Yes Printable Only
Instruction Appendix_C_CY2016 Plan Excluded Drugs Record Layout.pdf Yes Yes Printable Only
Instruction Appendix_C_CY2016 Plan Free First Fill File Record Layout.pdf Yes Yes Printable Only

Health Health Care Services

 

598 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 5,872 0 -148 -149 0 6,169
Annual IC Time Burden (Hours) 56,411 0 -533 -533 0 57,477
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk Appendix_C_MTMP_Module Provider_Qualified Provider crosswalk 08292014.pdf 12/19/2014
List of Changes PRA2016 List of Changes_2014_12_11.pdf 12/19/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.