CY2011 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262

PBP 2011 Data Entry System Screens

SECTION D – PLAN DEDUCTIBLE (COMBINED) – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – PLAN DEDUCTIBLE (COMBINED) – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – PLAN DEDUCTIBLE (IN-NETWORK) SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – PLAN DEDUCTIBLE (RPPO DIFFERENTIAL DEDUCTIBLE) – BASE 1

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – PLAN DEDUCTIBLE (RPPO DIFFERENTIAL DEDUCTIBLE) – BASE 2

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – PLAN DEDUCTIBLE (RPPO DIFFERENTIAL DEDUCTIBLE) – BASE 3

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – PLAN DEDUCTIBLE (OUT-OF-NETWORK) SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – PLAN DEDUCTIBLE (NON-NETWORK) SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – MAX ENROLLEE COST LIMIT (COMBINED) – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – MAX ENROLLEE COST LIMIT (COMBINED) – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – MAX ENROLLEE COST LIMIT (IN-NETWORK) SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – MAX ENROLLEE COST LIMIT (OUT-OF-NETWORK) SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – MAX ENROLLEE COST LIMIT (NON-NETWORK) SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – MAX PLAN BENEFIT COVERAGE SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – MAX PLAN BENEFIT COVERAGE (NON-NETWORK) SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D –PLAN PREMIUM/ REBATE REDUCTION SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – PFFS BALANCE BILLING SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D –MSA ANNUAL DEDUCTIBLE/DEPOSIT SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – MSA DEMO PLANS SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – NOTES SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – OPTIONAL SUPPLEMENTAL PACKAGE MANAGEMENT SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – OPTIONAL SUPPLEMENTAL – LABEL AND PREMIUM SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – OPTIONAL SUPPLEMENTAL – SERVICE CATEGORIES SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – OON-STEP-UP

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – OPTIONAL SUPPLEMENTAL -OON-OPTIONAL

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 7B – CHIROPRACTIC SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 7B – CHIROPRACTIC SERVICES – BASE 2 SCREEN

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SECTION D – STEP-UP – 7B – CHIROPRACTIC SERVICES – BASE 3 SCREEN
Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 7B – CHIROPRACTIC SERVICES – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 7F – PODIATRY SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 7F – PODIATRY SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 7F – PODIATRY SERVICES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 10B – TRANSPORTATION – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 10B – TRANSPORTATION – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 10B – TRANSPORTATION – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16A – PREVENTIVE DENTAL – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16A – PREVENTIVE DENTAL – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16A – PREVENTIVE DENTAL – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16A – PREVENTIVE DENTAL – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16A – PREVENTIVE DENTAL – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16A – PREVENTIVE DENTAL – BASE 6 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16B – COMPREHENSIVE DENTAL – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16B – COMPREHENSIVE DENTAL – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16B – COMPREHENSIVE DENTAL – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16B – COMPREHENSIVE DENTAL – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16B – COMPREHENSIVE DENTAL – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 16B – COMPREHENSIVE DENTAL – BASE 6 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 17A – EYE EXAMS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 17A – EYE EXAMS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 17A – EYE EXAMS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 17B – EYE WEAR – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 17B – EYE WEAR – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 17B – EYE WEAR – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 17B – EYE WEAR – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 17B – EYE WEAR – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 17B – EYE WEAR – BASE 6 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 18A – HEARING EXAMS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 18A – HEARING EXAMS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 18A – HEARING EXAMS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 18A – HEARING EXAMS – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 18B – HEARING AIDS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 18B – HEARING AIDS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 18B – HEARING AIDS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 18B – HEARING AIDS – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package

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PBP 2011 Data Entry System Screens

SECTION D – STEP-UP – 18B – HEARING AIDS – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package

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