Information Collection

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

IC 43667 under ICR 201412-0938-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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_CY2016 Plan ADD File Record Layout.pdf	Instruction
Appendix_C_CY2016 Plan Excluded Drugs Record Layout.pdf	Instruction
Appendix_C_CY2016 Plan Free First Fill File Record Layout.pdf	Instruction
Appendix_C_CY2016 Plan Gap Coverage File Layout.pdf	Instruction
Appendix_C_CY2016 Plan Home Infusion File Layout.pdf	Instruction
Appendix_C_CY2016 Plan Over The Counter File Record Layout.pdf	Instruction
Appendix_C_CY2016 Plan Prior Authorization Record Layout.pdf	Instruction
Appendix_C_CY2016 Plan Step Therapy Record Layout.pdf	Instruction
CMS-R-262 CY 2016 MTMP – Fees Page Mockups Appendix_C_MTMP_Fees Page Mockup 09082014.pdf	Form and Instruction
CMS-R-262 CY 2016 PBP Data Entry System Screens (section A) Appendix_C_PBP_2016_ screenshots_section_a_2014_12_05.pdf	Form
CMS-R-262 CY 2016 PBP Data Entry System Screens (section B) Appendix_C_PBP_2016_ screenshots_section_b_2014_12_05.pdf	Form
CMS-R-262 CY 2016 PBP Data Entry System Screens (section C) Appendix_C_PBP_2016_ screenshots_section_c_2014_12_05.pdf	Form
CMS-R-262 CY 2016 PBP Data Entry System Screens (section D) Appendix_C_PBP_2016_ screenshots_section_d_2014_12_04.pdf	Form
CMS-R-262 CY 2016 PBP Data Entry System Screens (section Rx) Appendix_C_PBP_2016_ screenshots_section_Rx_2014_12_05.pdf	Form
Appendix_C_MTMP_Module Provider_Qualified Provider crosswalk 08292014.pdf Crosswalk	IC Document
PRA2016 List of Changes_2014_12_11.pdf List of Changes	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

CY2016 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 422.312 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

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_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 â 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

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: 598

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	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,872	-148	-149	6,169
Annual IC Time Burden (Hours)	56,411	-533	-533	57,477
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
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.