Information Collection

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

IC 43667 under ICR 201901-0938-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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_CY2020_EXC_Record_Layout.pdf	Instruction
Appendix_C_CY2020_Formulary_IndicationBasedCoverage_Record_Layout.pdf	Instruction
Appendix_C_CY2020_Formulary_MED Opioid Strategy Submission.pdf	Instruction
Appendix_C_CY2020_Formulary_Opioid Strategy Layout.pdf	Instruction
Appendix_C_CY2020_Formulary_Plan_Additional_Demonstration_Drug_File_Reco....pdf	Instruction
Appendix_C_CY2020_Formulary_Plan_Excluded_Drugs_File_Record_Layout_508.pdf	Instruction
Appendix_C_CY2020_Formulary_Plan_Free_First_Fill_File_Record_Layout_508.pdf	Instruction
Appendix_C_CY2020_Formulary_Plan_Partial_Gap_Coverage_File_Record_Layout....pdf	Instruction
Appendix_C_CY2020_Formulary_Plan_Prior_Authorization_File_Record_Layout_....pdf	Instruction
Appendix_C_CY2020_PA_Record_Layout.pdf	Instruction
Appendix_C_CY2020_PAST_Criteria_Change_Request_ Submission.pdf	Instruction
Appendix_C_CY2020_PAST_Criteria_Change_Request_Record_Layout.pdf	Instruction
Appendix_C_Formulary_CY2020_OTC_Record_Layout.pdf	Instruction
Appendix_C_Formulary_Submission_File_Layout_508.pdf	Instruction
Appendix_C_FormularyProposed2019 Tier Model.txt	Instruction
R-262 MTMP CY2020 Enhancement Mockups Appendix_C_MTMP CY2020 Enhancements Mockups.pdf	Form and Instruction
R-262 Section A-1 APPENDIX_C_PBP2020_Screenshots-SectionA-Upload-2018-12-12.pdf	Form
R-262 #1a Inpatient Hospital-Acute – Base 1 APPENDIX_C_PBP2020_Screenshots-SectionB-2018-12-12.pdf	Form
R-262 #19 VBID/MA Uniformity Flexibility/SSBCI APPENDIX_C_PBP2020_Screenshots-SectionB-VBID-UF-SSBCI-2018-12-12.pdf	Form
R-262 OON – General – Base 1 APPENDIX_C_PBP2020_Screenshots-SectionC-2018-12-12.pdf	Form
R-262 Plan Deductible LPPO/RPPO Base 1 APPENDIX_C_PBP2020-Screenshots-SectionD-2018-12-12.pdf	Form
R-262 Medicare Rx General 1 APPENDIX_C_PBP2020-Screenshots-Section-Rx-2018-12-12.pdf	Form
R-262 VBID – General APPENDIX_C_PBP2020-Screenshots-Section-Rx-VBID-2018-12-12.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 422.316 42 CFR 423.251 42 CFR 422.306 42 CFR 422.318 42 CFR 422.252 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 422.320 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 422.256 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_CY2020_EXC_Record_Layout.pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_CY2020_Formulary_IndicationBasedCoverage_Record_Layout.pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_CY2020_Formulary_MED Opioid Strategy Submission.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2020_Formulary_Opioid Strategy Layout.pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_CY2020_Formulary_Plan_Additional_Demonstration_Drug_File_Reco....pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_CY2020_Formulary_Plan_Excluded_Drugs_File_Record_Layout_508.pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_CY2020_Formulary_Plan_Free_First_Fill_File_Record_Layout_508.pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_CY2020_Formulary_Plan_Partial_Gap_Coverage_File_Record_Layout....pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_CY2020_Formulary_Plan_Prior_Authorization_File_Record_Layout_....pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_CY2020_PA_Record_Layout.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_CY2020_PAST_Criteria_Change_Request_ Submission.pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_CY2020_PAST_Criteria_Change_Request_Record_Layout.pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_Formulary_CY2020_OTC_Record_Layout.pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_Formulary_Submission_File_Layout_508.pdf	Yes	Yes	Printable Only
Instruction			Appendix_C_FormularyProposed2019 Tier Model.txt	Yes	Yes	Printable Only
Form and Instruction	R-262	MTMP CY2020 Enhancement Mockups	Appendix_C_MTMP CY2020 Enhancements Mockups.pdf	Yes	Yes	Fillable Printable
Form	R-262	Section A-1	APPENDIX_C_PBP2020_Screenshots-SectionA-Upload-2018-12-12.pdf	Yes	Yes	Fillable Printable
Form	R-262	#1a Inpatient Hospital-Acute â Base 1	APPENDIX_C_PBP2020_Screenshots-SectionB-2018-12-12.pdf	Yes	Yes	Fillable Printable
Form	R-262	#19 VBID/MA Uniformity Flexibility/SSBCI	APPENDIX_C_PBP2020_Screenshots-SectionB-VBID-UF-SSBCI-2018-12-12.pdf	Yes	Yes	Fillable Printable
Form	R-262	OON â General â Base 1	APPENDIX_C_PBP2020_Screenshots-SectionC-2018-12-12.pdf	Yes	Yes	Fillable Printable
Form	R-262	Plan Deductible LPPO/RPPO Base 1	APPENDIX_C_PBP2020-Screenshots-SectionD-2018-12-12.pdf	Yes	Yes	Fillable Printable
Form	R-262	Medicare Rx General 1	APPENDIX_C_PBP2020-Screenshots-Section-Rx-2018-12-12.pdf	Yes	Yes	Fillable Printable
Form	R-262	VBID â General	APPENDIX_C_PBP2020-Screenshots-Section-Rx-VBID-2018-12-12.pdf	Yes	Yes	Fillable Printable

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: 570

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	Previously Approved
Annual Number of Responses for this IC	6,763	1,088	5,675
Annual IC Time Burden (Hours)	65,354	8,904	56,450
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.