CY2023 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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0763 can be found here:

Documents and Forms

Document Name Document Type
Appendix_C_CY2020_EXC_Record_Layout.pdf Instruction
Appendix_C_CY2020_EXC_Record_Layout.pdf Instruction
Appendix_C_CY2020_Formulary_IndicationBasedCoverage_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_MED Opioid Strategy Submission.pdf Instruction
Appendix_C_CY2020_Formulary_Opioid Strategy Layout.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_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_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_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_Partial_Gap_Coverage_File_Record_Layout....pdf Instruction
Appendix_C_CY2020_Formulary_Plan_Prior_Authorization_File_Record_Layout_....pdf Instruction
Appendix_C_CY2020_Formulary_Plan_Prior_Authorization_File_Record_Layout_....pdf Instruction
Appendix_C_CY2023_PA_Record_Layout.pdf Instruction
Appendix_C_CY2023_PA_Record_Layout.pdf Instruction
Appendix_C_Formulary_CY2020_OTC_Record_Layout.pdf Instruction
Appendix_C_Formulary_CY2020_OTC_Record_Layout.pdf Instruction
Appendix_C_Formulary_Submission_File_Layout_508.pdf Instruction
Appendix_C_Formulary_Submission_File_Layout_508.pdf Instruction
Appendix_C_FormularyProposed2019 Tier Model.txt Instruction
Appendix_C_FormularyProposed2019 Tier Model.txt Instruction
Appendix_C_CY2021_Formulary_LIS_Record_Layout.pdf Instruction
Appendix_C_CY2021_Formulary_LIS_Record_Layout.pdf Instruction
Appendix_C_CY2021_Formulary_PAST Criteria Change Request_Record_Layout.pdf Instruction
Appendix_C_CY2021_Formulary_PAST Criteria Change Request_Record_Layout.pdf Instruction
Appendix_C_CY2021_Formulary_PAST_Response_Record_Layout.pdf Instruction
Appendix_C_CY2021_Formulary_PAST_Response_Record_Layout.pdf Instruction
Appendix_C_Formulary2022_UMGD_Criteria_Response_Record_Layout.pdf Instruction
Appendix_C_Formulary2022_UMGD_Criteria_Response_Record_Layout.pdf Instruction
CMS-R-262 MTMP CY2022 Mockups Appendix_C_MTMP2023_Mockups_09282021.pdf Form and Instruction
CMS-R-262 MTMP CY2022 Mockups Appendix_C_MTMP2023_Mockups_09282021.pdf Form and Instruction
CMS-R-262 Section A-1 Appendix_C_PBP2023_Screenshots-SectionA-2021-12-27.pdf Form
CMS-R-262 Section A-1 Appendix_C_PBP2023_Screenshots-SectionA-2021-12-27.pdf Form
CMS-R-262 #1a Inpatient Hospital-Acute – Base 1 Appendix_C_PBP2023_Screenshots-SectionB-2021-12-27.pdf Form
CMS-R-262 #1a Inpatient Hospital-Acute – Base 1 Appendix_C_PBP2023_Screenshots-SectionB-2021-12-27.pdf Form
CMS-R-262 #19 VBID/MA Uniformity Flexibility/SSBCI Appendix_C_PBP2023_Screenshots-SectionB-VBID-UF-SSBCI-2021-12-27.pdf Form
CMS-R-262 #19 VBID/MA Uniformity Flexibility/SSBCI Appendix_C_PBP2023_Screenshots-SectionB-VBID-UF-SSBCI-2021-12-27.pdf Form
CMS-R-262 OON – General – Base 1 Appendix_C_PBP2023-Screenshots-SectionC-2021-12-27.pdf Form
CMS-R-262 OON – General – Base 1 Appendix_C_PBP2023-Screenshots-SectionC-2021-12-27.pdf Form
CMS-R-262 Plan Deductible LPPO/RPPO Base 1 Appendix_C_PBP2023-Screenshots-SectionD-2021-12-27.pdf Form
CMS-R-262 Plan Deductible LPPO/RPPO Base 1 Appendix_C_PBP2023-Screenshots-SectionD-2021-12-27.pdf Form
CMS-R-262 Medicare Rx General 1 Appendix_C_PBP2023-Screenshots-SectionRx-2021-12-27.pdf Form
CMS-R-262 Medicare Rx General 1 Appendix_C_PBP2023-Screenshots-SectionRx-2021-12-27.pdf Form
CMS-R-262 VBID – General Appendix_C_PBP2023_Screenshots_Section_Rx_VBID.pdf Form
CMS-R-262 VBID – General Appendix_C_PBP2023_Screenshots_Section_Rx_VBID.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CY2023 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 422.256 42 CFR 423.301 42 CFR 423.336 42 CFR 423.343 42 CFR 423.346 42 CFR 423.315 42 CFR 423.329 42 CFR 423.322 42 CFR 423.308 42 CFR 422.300 42 CFR 422.258 42 CFR 422.324 42 CFR 422.316 42 CFR 423.251 42 CFR 422.322 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 422.314 42 CFR 422.270 42 CFR 422.306 42 CFR 422.318 42 CFR 422.262 42 CFR 423.350 42 CFR 423.293 42 CFR 422.254 42 CFR 422.308 42 CFR 422.310 42 CFR 422.264 42 CFR 422.266 42 CFR 422.320

Information Collection 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_CY2023_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 CY2022 Mockups	Appendix_C_MTMP2023_Mockups_09282021.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix_C_FormularyProposed2019 Tier Model.txt	Yes	Yes	Printable Only
Form	CMS-R-262	Section A-1	Appendix_C_PBP2023_Screenshots-SectionA-2021-12-27.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	#1a Inpatient Hospital-Acute – Base 1	Appendix_C_PBP2023_Screenshots-SectionB-2021-12-27.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	#19 VBID/MA Uniformity Flexibility/SSBCI	Appendix_C_PBP2023_Screenshots-SectionB-VBID-UF-SSBCI-2021-12-27.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	OON – General – Base 1	Appendix_C_PBP2023-Screenshots-SectionC-2021-12-27.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	Plan Deductible LPPO/RPPO Base 1	Appendix_C_PBP2023-Screenshots-SectionD-2021-12-27.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	Medicare Rx General 1	Appendix_C_PBP2023-Screenshots-SectionRx-2021-12-27.pdf	Yes	Yes	Fillable Printable
Form	CMS-R-262	VBID – General	Appendix_C_PBP2023_Screenshots_Section_Rx_VBID.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_Formulary2022_UMGD_Criteria_Response_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: 785	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	8,405	315	8,090
Annual IC Time Burden (Hours)	76,378	2,340	74,038
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.