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Federal forms, ICRs, and supporting documents

Information Collection

CY2021 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

IC 43667 under ICR 202001-0938-005 · OMB 0938-0763.

Documents and Forms
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Instruction
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Instruction
Instruction
Instruction
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Instruction
Instruction
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Instruction
Instruction
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Instruction
Form and Instruction
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Information Collection (IC) Details

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CY2021 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 422.270 42 CFR 422.314 42 CFR 423.301 42 CFR 423.315 42 CFR 423.329 42 CFR 423.322 42 CFR 423.346 42 CFR 422.300 42 CFR 422.258 42 CFR 422.262 42 CFR 423.350 42 CFR 423.308 42 CFR 423.336 42 CFR 423.343 42 CFR 422.264 42 CFR 422.266 42 CFR 422.320 42 CFR 422.322 42 CFR 422.324 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 423.258 42 CFR 423.265 42 CFR 423.272 42 CFR 423.286 42 CFR 422.308 42 CFR 422.310 42 CFR 423.293 42 CFR 422.254 42 CFR 422.312 42 CFR 422.256

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Appendix_C_FormularyProposed2019 Tier Model.txt Yes Yes Printable Only
Form CMS-R-262 Section A-1 Appendix_C_PBP2021_Screenshots-SectionA-Upload-2019-12-09.pdf Yes Yes Fillable Printable
Form CMS-R-262 #1a Inpatient Hospital-Acute – Base 1 Appendix_C_PBP2021_Screenshots-SectionB-2019-12-09.pdf Yes Yes Fillable Printable
Form CMS-R-262 #19 VBID/MA Uniformity Flexibility/SSBCI Appendix_C_PBP2021_Screenshots-SectionB-VBID-UF-SSBCI-2019-12-09.pdf Yes Yes Fillable Printable
Form CMS-R-262 OON – General – Base 1 Appendix_C_PBP2021_Screenshots-SectionC-2019-12-09.pdf Yes Yes Fillable Printable
Form CMS-R-262 Plan Deductible LPPO/RPPO Base 1 Appendix_C_PBP2021-Screenshots-SectionD-2019-12-09.pdf Yes Yes Fillable Printable
Form CMS-R-262 Medicare Rx General 1 Appendix_C_PBP2021-Screenshots-Section-Rx-2019-12-09.pdf Yes Yes Fillable Printable
Form CMS-R-262 VBID – General Appendix_C_PBP2021-Screenshots-Section-Rx-VBID-2019-12-09.pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2021_Formulary_LIS_Record_Layout.pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2021_Formulary_PAST Criteria Change Request_Record_Layout.pdf Yes Yes Fillable Printable
Instruction Appendix_C_CY2021_Formulary_PAST_Response_Record_Layout.pdf Yes Yes Fillable Printable
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_Formulary_CY2020_OTC_Record_Layout.pdf Yes Yes Printable Only
Instruction Appendix_C_Formulary_Submission_File_Layout_508.pdf Yes Yes Printable Only
Form and Instruction CMS-R-262 MTMP CY2021 Enhancement Mockups Appendix_C_MTMP CY2021 Enhancement Mockups.pdf Yes Yes Fillable Printable

Health Health Care Services

 

672 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 7,266 0 503 0 0 6,763
Annual IC Time Burden (Hours) 67,368 0 2,014 0 0 65,354
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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