CY2017 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

The Plan Benefit Package (PBP) and Formulary Submission for Advantage (MA) Plans and Prescription Drug Plans (PDPs) (CMS-R-262)

OMB: 0938-0763

IC ID: 43667

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

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CY2017 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 423.258 42 CFR 423.265 42 CFR 422.258 42 CFR 422.262 42 CFR 422.250 42 CFR 422.252 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 422.254 42 CFR 422.256 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 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

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Appendix_C_CY2017_PBP_screenshots_Tier_Models.pdf Yes Yes Printable Only
Instruction Appendix_C_CY2017_Formulary_Plan_Additional_Demonstration_Drug_File_Record_Layout.pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2017_Formulary_Plan_Excluded_Drugs_File_Record_Layout.pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2017_Formulary_Plan_Free_First_Fill_File_Record_Layout.pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2017_Formulary_Plan_Over_The_Counter_File_Record_Layout (2).pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2017_Formulary_Plan_Over_The_Counter_File_Record_Layout.pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2017_Formulary_Plan_Partial_Gap_Coverage_File_Record_Layout.pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2017_Formulary_Plan_Prior_Authorization_File_Record_Layout.pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2017_Formulary_Plan_Submission_File_Record_Layout.pdf Yes Yes Fillable Printable
Form CMS-R-262 Medication Therapy Management Program (MTMP) Appendix_C_CY2017_MTMP_screenshots_PRA_9142015.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2017 PBP Data Entry System Screens - Section A Appendix_C_CY2017_PBP_ screenshots_section_a_and_upload_2015_12_04.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2017 PBP Data Entry System Screens - Section B Appendix_C_CY2017_PBP_ screenshots_section_b_2015_12_04.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2017 PBP Data Entry System Screens - Section B (VBID) Appendix_C_CY2017_PBP_ screenshots_section_b_VBID_2015_12_04.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2017 PBP Data Entry System Screens - Section C Appendix_C_CY2017_PBP_ screenshots_section_c_2015_12_04.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2017 PBP Data Entry System Screens - Section D Appendix_C_CY2017_PBP_ screenshots_section_d_2015_12_04.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2017 PBP Data Entry System Screens - Section Rx Appendix_C_CY2017_PBP_ screenshots_section_Rx_2015_12_04.pdf Yes Yes Fillable Printable
Form CMS-R-262 CY 2017 PBP Data Entry System Screens - Section Rx (VBID) Appendix_C_CY2017_PBP_ screenshots_section_Rx_VBID_2015_12_04.pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2017_Formulary_New File Layouts.pdf Yes Yes Fillable Printable

Health Health Care Services

 

552 25
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   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 5,448 0 0 -424 0 5,872
Annual IC Time Burden (Hours) 52,902 0 0 -3,509 0 56,411
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk (List of Changes) PRA2017 - List of Changes_2015_12_04.pdf 12/18/2015
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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