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pdfPBP 2015 Data Entry System Screens
Medicare Rx General 1
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 1 of 63
PBP 2015 Data Entry System Screens
Medicare Rx General 2
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 2 of 63
PBP 2015 Data Entry System Screens
Medicare Rx General 3
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 3 of 63
PBP 2015 Data Entry System Screens
Medicare Rx – Tier 2 Model
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 4 of 63
PBP 2015 Data Entry System Screens
Medicare Rx – Tier 3 Model
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 5 of 63
PBP 2015 Data Entry System Screens
Medicare Rx – Tier 4 Model
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 6 of 63
PBP 2015 Data Entry System Screens
Medicare Rx – Tier 5 Model
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 7 of 63
PBP 2015 Data Entry System Screens
Medicare Rx – Tier 6 Model
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 8 of 63
PBP 2015 Data Entry System Screens
Medicare Rx – Medicare‐Medicaid Formulary Tier Model 2
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 9 of 63
PBP 2015 Data Entry System Screens
Medicare Rx – Medicare‐Medicaid Formulary Tier Model 3
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 10 of 63
PBP 2015 Data Entry System Screens
Medicare Rx – Medicare‐Medicaid Formulary Tier Model 4
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 11 of 63
PBP 2015 Data Entry System Screens
Medicare Rx – Medicare‐Medicaid Formulary Tier Model 5
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 12 of 63
PBP 2015 Data Entry System Screens
Medicare Rx – Medicare‐Medicaid Formulary Tier Model 6
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 13 of 63
PBP 2015 Data Entry System Screens
Defined Standard – ICL and OOP Threshold
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 14 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent Characteristics
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 15 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 16 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – Tier Type and Cost Share Structure – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 17 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – Tier Locations – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 18 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – Retail Pharmacy Location Supply – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 19 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – Mail Order Location Supply – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 20 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – OON and LTC Location Supply – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 21 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – Retail Pharmacy Copayment and Coinsurance – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 22 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – Mail Order Copayment and Coinsurance – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 23 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – OON and LTC Copayment and Coinsurance – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 24 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – OOP Threshold
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 25 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – Tier Type – Post‐OOP Threshold
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 26 of 63
PBP 2015 Data Entry System Screens
Actuarially Equivalent – Tier Cost Sharing – Post‐OOP Threshold
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 27 of 63
PBP 2015 Data Entry System Screens
Alternative – Deductible
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 28 of 63
PBP 2015 Data Entry System Screens
Alternative – Enhanced Alternative Characteristics
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 29 of 63
PBP 2015 Data Entry System Screens
Alternative – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 30 of 63
PBP 2015 Data Entry System Screens
Alternative – Tier Type and Cost Share Structure – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 31 of 63
PBP 2015 Data Entry System Screens
Alternative – Tier Locations – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 32 of 63
PBP 2015 Data Entry System Screens
Alternative – Retail Pharmacy Location Supply – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 33 of 63
PBP 2015 Data Entry System Screens
Alternative – Mail Order Location Supply – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 34 of 63
PBP 2015 Data Entry System Screens
Alternative – OON and LTC Location Supply – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 35 of 63
PBP 2015 Data Entry System Screens
Alternative – Retail Pharmacy Copayment and Coinsurance – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 36 of 63
PBP 2015 Data Entry System Screens
Alternative – Mail Order Copayment and Coinsurance – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 37 of 63
PBP 2015 Data Entry System Screens
Alternative – OON and LTC Copayment and Coinsurance – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 38 of 63
PBP 2015 Data Entry System Screens
Alternative – Pre‐ICL Medicare‐Medicaid
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 39 of 63
PBP 2015 Data Entry System Screens
Alternative – Medicare‐Medicaid Tier Type – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 40 of 63
PBP 2015 Data Entry System Screens
Alternative – Medicare‐Medicaid Tier Locations – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 41 of 63
PBP 2015 Data Entry System Screens
Alternative – Medicare‐Medicaid Retail Pharmacy Location Supply ‐ Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 42 of 63
PBP 2015 Data Entry System Screens
Alternative – Medicare‐Medicaid Mail Order Location Supply – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 43 of 63
PBP 2015 Data Entry System Screens
Alternative – Medicare‐Medicaid OON and LTC Location Supply – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 44 of 63
PBP 2015 Data Entry System Screens
Alternative – Medicare‐Medicaid Copayment – Pre‐ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 45 of 63
PBP 2015 Data Entry System Screens
Alternative – ICL
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 46 of 63
PBP 2015 Data Entry System Screens
Alternative – Gap Coverage
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 47 of 63
PBP 2015 Data Entry System Screens
Alternative – Tier Type and Cost Share Structure – Gap
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 48 of 63
PBP 2015 Data Entry System Screens
Alternative – Tier Coverage – Gap
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 49 of 63
PBP 2015 Data Entry System Screens
Alternative – Tier Locations – Gap
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 50 of 63
PBP 2015 Data Entry System Screens
Alternative – Retail Pharmacy Location Supply – Gap
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 51 of 63
PBP 2015 Data Entry System Screens
Alternative – Mail Order Location Supply – Gap
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 52 of 63
PBP 2015 Data Entry System Screens
Alternative – OON and LTC Location Supply – Gap
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 53 of 63
PBP 2015 Data Entry System Screens
Alternative – Retail Pharmacy Copayment and Coinsurance – Gap
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 54 of 63
PBP 2015 Data Entry System Screens
Alternative – Mail Order Copayment and Coinsurance – Gap
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 55 of 63
PBP 2015 Data Entry System Screens
Alternative – OON and LTC Copayment and Coinsurance – Gap
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 56 of 63
PBP 2015 Data Entry System Screens
Alternative – OOP Threshold
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 57 of 63
PBP 2015 Data Entry System Screens
Alternative – Tier Type – Post‐OOP Threshold
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 58 of 63
PBP 2015 Data Entry System Screens
Alternative – Tier Cost Sharing Post‐OOP Threshold
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 59 of 63
PBP 2015 Data Entry System Screens
Alternative – Medicare‐Medicaid Post‐OOP Threshold
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 60 of 63
PBP 2015 Data Entry System Screens
Alternative – Tier Type and Tier Cost Sharing Post‐OOP Medicare‐Medicaid
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 61 of 63
PBP 2015 Data Entry System Screens
Defined Standard – Locations and Location Supply
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 62 of 63
PBP 2015 Data Entry System Screens
Medicare Rx – Notes
Fu Associates, Ltd.
CY 2015 PBP – Section Rx
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 63 of 63
| File Type | application/pdf |
| File Title | Microsoft Word - PBP_2015_screenshots_section_ Rx_2013_12_19.docx |
| Author | bloss |
| File Modified | 2013-12-20 |
| File Created | 2013-12-20 |