Information Collection

CY2019 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

IC 43667 under ICR 201801-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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_CY2019_Formulary_MED Opioid Strategy Submission.pdf	Instruction
Appendix_C_CY2019_Formulary_Opiod Strategy Layout_final.pdf	Instruction
Appendix_C_CY2019_Formulary_Plan_Additional_Demonstration_Drug_File_Record_Layout_508.pdf	Instruction
Appendix_C_CY2019_Formulary_Plan_Excluded_Drugs_File_Record_Layout_508.pdf	Instruction
Appendix_C_CY2019_Formulary_Plan_Free_First_Fill_File_Record_Layout_508.pdf	Instruction
Appendix_C_CY2019_Formulary_Plan_Partial_Gap_Coverage_File_Record_Layout_508.pdf	Instruction
Appendix_C_CY2019_Formulary_Plan_Prior_Authorization_File_Record_Layout_508.pdf	Instruction
Appendix_C_Formulary_CY2019_OTC_Record_Layout.pdf	Instruction
Appendix_C_Formulary_Submission_File_Layout_508.pdf	Instruction
Appendix_C_FormularyProposed2019 Tier Model.txt	Instruction
CMS-R-262 Medication Therapy Management Program (MTMP) Appendix_C_MTMP_508Screenshots_09072017.pdf	Form
CMS-R-262 CY 2019 PBP Data Entry System Screens - Section A and Up Appendix_C_PBP_2019_ screenshots_section_a_and_upload_2017_11_17.pdf	Form
CMS-R-262 CY 2019 PBP Data Entry System Screens - Section B Appendix_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf	Form
CMS-R-262 CY 2019 PBP Data Entry System Screens - Section B (VBID) Appendix_C_PBP_2019_ screenshots_section_b_VBID_UF_2017_11_21.pdf	Form
CMS-R-262 CY 2019 PBP Data Entry System Screens - Section C Appendix_C_PBP_2019_ screenshots_section_c_2017_11_16.pdf	Form
CMS-R-262 CY 2019 PBP Data Entry System Screens - Section D Appendix_C_PBP_2019_ screenshots_section_d_2017_11_17.pdf	Form
CMS-R-262 CY 2019 PBP Data Entry System Screens - Section Rx Appendix_C_PBP_2019_ screenshots_section_Rx_2017_11_17.pdf	Form
CMS-R-262 CY 2019 PBP Data Entry System Screens - Section Rx (VBID Appendix_C_PBP_2019_ screenshots_section_Rx_VBID_2017_11_17.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

CY2019 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 422.256 42 CFR 422.252 42 CFR 423.251 42 CFR 422.306 42 CFR 422.250 42 CFR 422.304 42 CFR 423.346 42 CFR 423.350 42 CFR 423.258 42 CFR 423.265 42 CFR 423.272 42 CFR 423.286 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 422.270 42 CFR 422.300 42 CFR 422.258 42 CFR 422.262 42 CFR 422.308 42 CFR 422.310 42 CFR 423.293 42 CFR 422.254 42 CFR 422.312 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 422.264 42 CFR 422.266

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_CY2019_Formulary_MED Opioid Strategy Submission.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2019_Formulary_Opiod Strategy Layout_final.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2019_Formulary_Plan_Additional_Demonstration_Drug_File_Record_Layout_508.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2019_Formulary_Plan_Excluded_Drugs_File_Record_Layout_508.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2019_Formulary_Plan_Free_First_Fill_File_Record_Layout_508.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2019_Formulary_Plan_Partial_Gap_Coverage_File_Record_Layout_508.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2019_Formulary_Plan_Prior_Authorization_File_Record_Layout_508.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_Formulary_CY2019_OTC_Record_Layout.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	Medication Therapy Management Program (MTMP)	Appendix_C_MTMP_508Screenshots_09072017.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	CY 2019 PBP Data Entry System Screens - Section A and Upload	Appendix_C_PBP_2019_ screenshots_section_a_and_upload_2017_11_17.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	CY 2019 PBP Data Entry System Screens - Section B	Appendix_C_PBP_2019_ screenshots_section_b_2017_11_16.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	CY 2019 PBP Data Entry System Screens - Section B (VBID)	Appendix_C_PBP_2019_ screenshots_section_b_VBID_UF_2017_11_21.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	CY 2019 PBP Data Entry System Screens - Section C	Appendix_C_PBP_2019_ screenshots_section_c_2017_11_16.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	CY 2019 PBP Data Entry System Screens - Section D	Appendix_C_PBP_2019_ screenshots_section_d_2017_11_17.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	CY 2019 PBP Data Entry System Screens - Section Rx	Appendix_C_PBP_2019_ screenshots_section_Rx_2017_11_17.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	CY 2019 PBP Data Entry System Screens - Section Rx (VBID)	Appendix_C_PBP_2019_ screenshots_section_Rx_VBID_2017_11_17.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_Formulary_Submission_File_Layout_508.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_FormularyProposed2019 Tier Model.txt	Yes	Yes	Fillable Fileable

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: 520

Number of Respondents for Small Entity: 25

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

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	5,675	446	44	5,185
Annual IC Time Burden (Hours)	56,450	5,397	434	50,619
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.