Information Collection

CY2023 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

IC 43667 under ICR 202302-0938-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-R-262 CY2023 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262) Form and Instruction
CMS-R-262 MTM2024 Submission Changes Appendix_C_MTM2024 Submission Changes.pdf Form and Instruction
CMS-R-262 MTM2024 Submission Changes Appendix_C_MTM2024 Submission Changes.pdf Form and Instruction
CMS-R-262 Benefit Details-Service Categories 1-10 Appendix_C_PBP2024 Benefit Details-Service Categories 1-10.pdf Form and Instruction
CMS-R-262 Benefit Details-Service Categories 1-10 Appendix_C_PBP2024 Benefit Details-Service Categories 1-10.pdf Form and Instruction
CMS-R-262 Benefit Details-Service Categories 11-20 Appendix_C_PBP2024 Benefit Details-Service Categories 11-20.pdf Form and Instruction
CMS-R-262 Benefit Details-Service Categories 11-20 Appendix_C_PBP2024 Benefit Details-Service Categories 11-20.pdf Form and Instruction
CMS-R-262 Cost Share Groups Appendix_C_PBP2024 Cost Share Groups.pdf Form and Instruction
CMS-R-262 Cost Share Groups Appendix_C_PBP2024 Cost Share Groups.pdf Form and Instruction
CMS-R-262 General Setup Appendix_C_PBP2024 General Setup.pdf Form and Instruction
CMS-R-262 General Setup Appendix_C_PBP2024 General Setup.pdf Form and Instruction
CMS-R-262 Section Rx Appendix_C_PBP2024 Section Rx.pdf Form and Instruction
CMS-R-262 Section Rx Appendix_C_PBP2024 Section Rx.pdf Form and Instruction
CMS-R-262 VBID Rx Appendix_C_PBP2024 VBID Rx.pdf Form and Instruction
CMS-R-262 VBID Rx Appendix_C_PBP2024 VBID Rx.pdf Form and Instruction
CMS-R-262 VBID-UF-SSBCI Packages Appendix_C_PBP2024 VBID-UF-SSBCI Packages.pdf Form and Instruction
CMS-R-262 VBID-UF-SSBCI Packages Appendix_C_PBP2024 VBID-UF-SSBCI Packages.pdf Form and Instruction

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 422.314 42 CFR 422.270 42 CFR 422.306 42 CFR 423.301 42 CFR 423.336 42 CFR 422.256 42 CFR 422.312 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 422.318 42 CFR 422.262 42 CFR 423.350 42 CFR 422.308 42 CFR 422.310 42 CFR 422.264 42 CFR 422.266 42 CFR 422.320 42 CFR 423.293 42 CFR 422.254

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-262	MTM2024 Submission Changes	Appendix_C_MTM2024 Submission Changes.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	Benefit Details-Service Categories 1-10	Appendix_C_PBP2024 Benefit Details-Service Categories 1-10.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	Benefit Details-Service Categories 11-20	Appendix_C_PBP2024 Benefit Details-Service Categories 11-20.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	Cost Share Groups	Appendix_C_PBP2024 Cost Share Groups.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	General Setup	Appendix_C_PBP2024 General Setup.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	Section Rx	Appendix_C_PBP2024 Section Rx.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	VBID Rx	Appendix_C_PBP2024 VBID Rx.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	VBID-UF-SSBCI Packages	Appendix_C_PBP2024 VBID-UF-SSBCI Packages.pdf	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: 839	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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	8,932	527	8,405
Annual IC Time Burden (Hours)	57,126	-19,252	76,378
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.