CY2013 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)

OMB: 0938-0763

IC ID: 43667

Documents and Forms
Document Name
Document Type
Other-Screenshot
Other-Screenshot
Other-Screenshot
Other-Screenshot
Other-Screenshot
Other-Screenshot
Other-Screenshot
Other-Screenshot
Other-Screenshot
Other-Screenshot
Other-Screenshot
Other-Screenshot
Other-Screenshot
Other-Screenshot
IC Document
Information Collection (IC) Details

View Information Collection (IC)

CY2013 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 422.250 42 CFR 422.252 42 CFR 422.254 42 CFR 422.256 42 CFR 422.258 42 CFR 422.262 42 CFR 422.264 42 CFR 422.266 42 CFR 422.270 42 CFR 422.300 42 CFR 422.304 42 CFR 422.306 42 CFR 422.308 42 CFR 422.310 42 CFR 422.312 42 CFR 422.314 42 CFR 422.316 42 CFR 422.318 42 CFR 422.320 42 CFR 422.322 42 CFR 422.324 42 CFR 423.251 42 CFR 423.258 42 CFR 423.265 42 CFR 423.272 42 CFR 423.286 42 CFR 423.293 42 CFR 423.301 42 CFR 423.308 42 CFR 423.315 42 CFR 423.322 42 CFR 423.329 42 CFR 423.336 42 CFR 423.343 42 CFR 423.346 42 CFR 423.350

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Screenshot Appendix_C_CY2013 Plan Prior Authorization Record Layout 12062011.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_CY2013 Plan Step Therapy Record Layout 12062011.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_MTMP screenshots_12132011.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_PBP_2013_screenshots_Medicare_RX_Drugs_2011_12_08.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_PBP_2013_screenshots_section_a_2011_12_08.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_PBP_2013_screenshots_section_b_2011_12_08.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_PBP_2013_screenshots_section_c_2011_12_08.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_PBP_2013_screenshots_section_d_2011_12_08.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_CY2013 Plan Excluded Drugs Record Layout 12062011.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_CY2013 Plan Formulary Submission File Record Layout 12062011.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_CY2013 Plan Free First Fill File Record Layout 12062011.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_CY2013 Plan Gap Coverage File Layout 12062011.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_CY2013 Plan Home Infusion File Layout 12062011.pdf Yes Yes Fillable Printable
Other-Screenshot Appendix_C_CY2013 Plan Over The Counter File Record Layout 12062011.pdf Yes Yes Fillable Printable

Health Health Care Services

 

635 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 6,013 0 0 -146 0 6,159
Annual IC Time Burden (Hours) 53,117 0 0 -1,290 0 54,407
Annual IC Cost Burden (Dollars) 4,103,426 0 0 -85,932 0 4,189,358

Title Document Date Uploaded
Appendix_B_PRA2013ListofChanges_12132011 Appendix_B_PRA2013ListofChanges_12132011.docx 01/16/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
© 2025 OMB.report | Privacy Policy