CMS-R-262 CY 2017 PBP Data Entry System Screens - Section Rx

Medicare Rx General 1

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 1 of 68

Medicare Rx General 2

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 2 of 68

Medicare Rx General 3

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 3 of 68

CY 2017 PBP Data Entry System Screens

Medicare Rx – Tier Model (when a tier includes 2 tiers)

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 4 of 68

CY 2017 PBP Data Entry System Screens

Medicare Rx- Tier Model (when a tier includes 3 tiers)

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 5 of 68

CY 2017 PBP Data Entry System Screens

Medicare Rx – Tier Model (when a tier includes 4 tiers)

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 6 of 68

CY 2017 PBP Data Entry System Screens

Medicare Rx – Tier Model (when a tier includes 5 tiers)

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 7 of 68

CY 2017 PBP Data Entry System Screens

Medicare Rx – Tier Model (when a tier includes 6 tiers)

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 8 of 68

CY 2017 PBP Data Entry System Screens

Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 2 tiers)

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 9 of 68

CY 2017 PBP Data Entry System Screens

Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 3 tiers)

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 10 of 68

CY 2017 PBP Data Entry System Screens

Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 4 tiers)

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 11 of 68

CY 2017 PBP Data Entry System Screens

Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 5 tiers)

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 12 of 68

CY 2017 PBP Data Entry System Screens

Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 6 tiers)

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 13 of 68

CY 2017 PBP Data Entry System Screens

Defined Standard – ICL and OOP Threshold

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 14 of 68

Actuarially Equivalent Characteristics

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 15 of 68

Actuarially Equivalent – Pre-ICL

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 16 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 17 of 68

CY 2017 PBP Data Entry System Screens

Actuarially Equivalent – Tier Locations – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 18 of 68

CY 2017 PBP Data Entry System Screens

Actuarially Equivalent – Retail Pharmacy Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 19 of 68

CY 2017 PBP Data Entry System Screens

Actuarially Equivalent – Mail Order Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 20 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 21 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 22 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 23 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 24 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 25 of 68

Actuarially Equivalent – OOP Threshold

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 26 of 68

CY 2017 PBP Data Entry System Screens

Actuarially Equivalent – Tier Type – Post-OOP Threshold

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 27 of 68

CY 2017 PBP Data Entry System Screens

Actuarially Equivalent – Tier Cost Sharing – Post-OOP Threshold

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 28 of 68

Alternative – Deductible

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 29 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Enhanced Alternative Characteristics

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 30 of 68

Alternative – Pre-ICL

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 31 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 32 of 68

Alternative – Tier Locations – Pre-ICL

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 33 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Retail Pharmacy Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 34 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Mail Order Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 35 of 68

CY 2017 PBP Data Entry System Screens

Alternative – OON – LTC Location Supply – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 36 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Retail Pharmacy Copayment and Coinsurance – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 37 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Mail Order Copayment and Coinsurance – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 38 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 39 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Daily Copayment Amount Cost Sharing – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 40 of 68

Alternative – Pre-ICL Medicare-Medicaid

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 41 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Tier Type – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 42 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Tier Locations – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 43 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 44 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 45 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 46 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Copayment – Pre-ICL

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 47 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Daily Copayment Amount Cost Sharing

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 48 of 68

Alternative – ICL

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 49 of 68

Alternative – Gap Coverage

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 50 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Tier Type and Cost Share Structure – Gap

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 51 of 68

Alternative – Tier Coverage – Gap

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 52 of 68

Alternative – Tier Locations – Gap

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 53 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Retail Pharmacy Location Supply – Gap

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 54 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Mail Order Location Supply – Gap

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 55 of 68

CY 2017 PBP Data Entry System Screens

Alternative – OON and LTC Location Supply – Gap

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 56 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Retail Pharmacy Copayment and Coinsurance – Gap

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 57 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Mail Order Copayment and Coinsurance – Gap

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 58 of 68

CY 2017 PBP Data Entry System Screens

Alternative – OON and LTC Copayment and Coinsurance – Gap

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 59 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Daily Copayment Amount Cost Sharing – Gap

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 60 of 68

Alternative – OOP Threshold

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 61 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Tier Type Post-OOP Threshold

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 62 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Tier Cost Sharing Post-OOP Threshold

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 63 of 68

CY 2017 PBP Data Entry System Screens

Alternative – Medicare-Medicaid Post-OOP Threshold

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 64 of 68

CY 2017 PBP Data Entry System Screens

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

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 65 of 68

CY 2017 PBP Data Entry System Screens

Defined Standard – Locations and Location Supply

Fu Associates, Ltd.

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 66 of 68

Medicare Rx – Attestations

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 67 of 68

Medicare RX – Notes

Fu Associates, Ltd.

CY 2017 PBP Data Entry System Screens

CY2017 PBP – Section Rx
12/4/2015
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 68 of 68