Information Collection

CY2027 Plan Benefit Package (PBP) Software and Formulary Submission

IC 43667 under ICR 202603-0938-012 · OMB 0938-0763.

Documents and Forms

Document Name Document Type
Form CMS-R-262 MTM2027 Mockup CY2027 Plan Benefit Package (PBP) Software and Formulary Submission Form and Instruction
Form CMS-R-262 Benefit Details-Service Categories 1-10 CY2027 Plan Benefit Package (PBP) Software and Formulary Submission Form and Instruction
Form CMS-R-262 Benefit Details-Service Categories 11-15 CY2027 Plan Benefit Package (PBP) Software and Formulary Submission Form and Instruction
Form CMS-R-262 Cost Share Groups CY2027 Plan Benefit Package (PBP) Software and Formulary Submission Form and Instruction
Form CMS-R-262 General Setup CY2027 Plan Benefit Package (PBP) Software and Formulary Submission Form and Instruction
Form CMS-R-262 Section Rx CY2027 Plan Benefit Package (PBP) Software and Formulary Submission Form and Instruction
Form CMS-R-262 VBID Rx CY2027 Plan Benefit Package (PBP) Software and Formulary Submission Form and Instruction
Form CMS-R-262 VBID-UF-SSBCI Packages CY2027 Plan Benefit Package (PBP) Software and Formulary Submission Form and Instruction
Form CMS-R-262 CY 2027 Prior Authorization File Record Layout CY2027 Plan Benefit Package (PBP) Software and Formulary Submission Form and Instruction
Form CMS-R-262 CY 2027 Step Therapy File Record Layout CY2027 Plan Benefit Package (PBP) Software and Formulary Submission Form and Instruction
Form CMS-R-262 Benefit Details - Service Categories 16-20 CY2027 Plan Benefit Package (PBP) Software and Formulary Submission Form and Instruction
CMS-R-262 MTM2027 Mockup Appendix_C_CY 2027 MTM Screenshots for PRA.pdf Form and Instruction
CMS-R-262 Benefit Details-Service Categories 1-10 Appendix C_PBP2027 Benefit Details - Service Categories 1-10.pdf Form and Instruction
CMS-R-262 Benefit Details-Service Categories 11-15 Appendix_C_PBP2027 Benefit Details - Service Categories 11-15.pdf Form and Instruction
CMS-R-262 Cost Share Groups Appendix_C_PBP2027 Cost Share Groups.pdf Form and Instruction
CMS-R-262 General Setup Appendix_C_PBP2027 General Setup.pdf Form and Instruction
CMS-R-262 Section Rx Appendix_C_PBP2027 Section Rx.pdf Form and Instruction
CMS-R-262 VBID Rx Appendix_C_PBP2026 VBID Rx.pdf Form and Instruction
CMS-R-262 VBID-UF-SSBCI Packages Appendix C_PBP2027 UF-SSBCI Packages.pdf Form and Instruction
CMS-R-262 CY 2027 Prior Authorization File Record Layout CY2027_PA_Record_Layout.pdf Form and Instruction
CMS-R-262 CY 2027 Step Therapy File Record Layout CY2027_ST_Record_Layout.pdf Form and Instruction
CMS-R-262 Benefit Details - Service Categories 16-20 Appendix_C_PBP2027 Benefit Details - Service Categories 16-20.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CY2027 Plan Benefit Package (PBP) Software and Formulary Submission	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 422.306 42 CFR 422.316 42 CFR 423.251 42 CFR 422.314 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 422.270 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 423.293 42 CFR 422.254 42 CFR 423.350 42 CFR 422.262 42 CFR 422.308 42 CFR 422.310 42 CFR 422.264 42 CFR 422.324 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 422.266 42 CFR 422.320

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	MTM2027 Mockup	Appendix_C_CY 2027 MTM Screenshots for PRA.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	Benefit Details-Service Categories 1-10	Appendix C_PBP2027 Benefit Details - Service Categories 1-10.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	Benefit Details-Service Categories 11-15	Appendix_C_PBP2027 Benefit Details - Service Categories 11-15.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	Cost Share Groups	Appendix_C_PBP2027 Cost Share Groups.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	General Setup	Appendix_C_PBP2027 General Setup.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	Section Rx	Appendix_C_PBP2027 Section Rx.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	VBID Rx	Appendix_C_PBP2026 VBID Rx.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	VBID-UF-SSBCI Packages	Appendix C_PBP2027 UF-SSBCI Packages.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	CY 2027 Prior Authorization File Record Layout	CY2027_PA_Record_Layout.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	CY 2027 Step Therapy File Record Layout	CY2027_ST_Record_Layout.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-262	Benefit Details - Service Categories 16-20	Appendix_C_PBP2027 Benefit Details - Service Categories 16-20.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: 764	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	8,068	-269	8,337
Annual IC Time Burden (Hours)	44,178	-1,848	46,026
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.

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