CMS-R-262 CY 2016 PBP Data Entry System Screens (section Rx)

The Plan Benefit Package (PBP) and Formulary Submission for Advantage (MA) Plans and Prescription Drug Plans (PDPs) (CMS-R-262)

Appendix_C_PBP_2016_ screenshots_section_Rx_2014_12_05

CY2016 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

OMB: 0938-0763

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0763 can be found here:
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Medicare Rx General 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 1 of 68

Medicare Rx General 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 2 of 68

Medicare Rx General 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 3 of 68

Medicare Rx – Tier 2 Model

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 4 of 68

Medicare Rx- Tier 3 Model

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 5 of 68

Medicare Rx – Tier 4 Model

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 6 of 68

Medicare Rx – Tier 5 Model

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 7 of 68

Medicare Rx – Tier 6 Model

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 8 of 68

CY 2016 PBP Data Entry System Screens

Medicare Rx – Medicare-Medicaid Formulary Tier Model 2

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 9 of 68

CY 2016 PBP Data Entry System Screens

Medicare Rx – Medicare-Medicaid Formulary Tier Model 3

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 10 of 68

CY 2016 PBP Data Entry System Screens

Medicare Rx – Medicare-Medicaid Formulary Tier Model 4

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 11 of 68

CY 2016 PBP Data Entry System Screens

Medicare Rx – Medicare-Medicaid Formulary Tier Model 5

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 12 of 68

CY 2016 PBP Data Entry System Screens

Medicare Rx – Medicare-Medicaid Formulary Tier Model 6

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 13 of 68

CY 2016 PBP Data Entry System Screens

Defined Standard – ICL and OOP Threshold

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 14 of 68

Actuarially Equivalent Characteristics

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 15 of 68

Actuarially Equivalent – Pre-ICL

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 16 of 68

CY 2016 PBP Data Entry System Screens

Actuarially Equivalent – Tier Type and Cost Share Structure – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 17 of 68

CY 2016 PBP Data Entry System Screens

Actuarially Equivalent – Tier Locations – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 18 of 68

CY 2016 PBP Data Entry System Screens

Actuarially Equivalent – Retail Pharmacy Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 19 of 68

CY 2016 PBP Data Entry System Screens

Actuarially Equivalent – Mail Order Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 20 of 68

CY 2016 PBP Data Entry System Screens

Actuarially Equivalent – OON and LTC Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 21 of 68

CY 2016 PBP Data Entry System Screens

Actuarially Equivalent – Retail Pharmacy Copayment and Coinsurance – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 22 of 68

CY 2016 PBP Data Entry System Screens

Actuarially Equivalent – Mail Order Copayment and Coinsurance – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 23 of 68

CY 2016 PBP Data Entry System Screens

Actuarially Equivalent – OON and LTC Copayment and Coinsurance – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 24 of 68

CY 2016 PBP Data Entry System Screens

Actuarially Equivalent – Daily Copayment Amount Cost Sharing – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 25 of 68

Actuarially Equivalent – OOP Threshold

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 26 of 68

CY 2016 PBP Data Entry System Screens

Actuarially Equivalent – Tier Type – Post-OOP Threshold

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 27 of 68

CY 2016 PBP Data Entry System Screens

Actuarially Equivalent – Tier Cost Sharing – Post-OOP Threshold

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 28 of 68

Alternative – Deductible

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 29 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Enhanced Alternative Characteristics

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 30 of 68

Alternative – Pre-ICL

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 31 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Tier Type and Cost Share Structure – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 32 of 68

Alternative – Tier Locations – Pre-ICL

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 33 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Retail Pharmacy Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 34 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Mail Order Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 35 of 68

CY 2016 PBP Data Entry System Screens

Alternative – OON – LTC Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 36 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Retail Pharmacy Copayment and Coinsurance – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 37 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Mail Order Copayment and Coinsurance – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 38 of 68

CY 2016 PBP Data Entry System Screens

Alternative – OON and LTC Copayment and Coinsurance – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 39 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Daily Copayment Amount Cost Sharing – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 40 of 68

Alternative – Pre-ICL Medicare-Medicaid

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 41 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Tier Type – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 42 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Tier Locations – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 43 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Retail Pharmacy Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 44 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Mail Order Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 45 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Medicare-Medicaid OON and LTC Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 46 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Copayment – Pre-ICL

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 47 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Daily Copayment Amount Cost Sharing

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 48 of 68

Alternative – ICL

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 49 of 68

Alternative – Gap Coverage

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 50 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Tier Type and Cost Share Structure – Gap

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 51 of 68

Alternative – Tier Coverage – Gap

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 52 of 68

Alternative – Tier Locations – Gap

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 53 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Retail Pharmacy Location Supply – Gap

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 54 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Mail Order Location Supply – Gap

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 55 of 68

CY 2016 PBP Data Entry System Screens

Alternative – OON and LTC Location Supply – Gap

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 56 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Retail Pharmacy Copayment and Coinsurance – Gap

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 57 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Mail Order Copayment and Coinsurance – Gap

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 58 of 68

CY 2016 PBP Data Entry System Screens

Alternative – OON and LTC Copayment and Coinsurance – Gap

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 59 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Daily Copayment Amount Cost Sharing – Gap

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 60 of 68

Alternative – OOP Threshold

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 61 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Tier Type Post-OOP Threshold

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 62 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Tier Cost Sharing Post-OOP Threshold

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 63 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Post-OOP Threshold

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 64 of 68

CY 2016 PBP Data Entry System Screens

Alternative – Tier Type and Tier Cost Sharing Post-OOP Medicare and Medicaid

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 65 of 68

CY 2016 PBP Data Entry System Screens

Defined Standard – Locations and Location Supply

Fu Associates, Ltd.

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 66 of 68

Medicare Rx – Attestations

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 67 of 68

Medicare RX – Notes

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section Rx
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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File Type	application/pdf
File Title	CY 2016 PBP Data Entry System Screens
Author	Scott Meyer
File Modified	2014-12-05
File Created	2014-12-05