CMS-R-262 CY 2019 PBP Data Entry System Screens - Section D

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

Appendix_C_PBP_2019_ screenshots_section_d_2017_11_17

CY2019 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⚠️ Notice: This form may be outdated.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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Plan Deductible LPPO/RPPO Base 1

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible LPPO/RPPO Base 2

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible LPPO/RPPO Base 3

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible LPPO/RPPO Base 4

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible LPPO/RPPO Base 5

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible LPPO/RPPO Base 6

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 6 of 68

CY 2019 PBP Data Entry System Screens

Deductible for LPPO/RPPO Mandatory Supplemental Benefits – Base 1

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 7 of 68

CY 2019 PBP Data Entry System Screens

Deductible for LPPO/RPPO Mandatory Supplemental Benefits – Base 2

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 8 of 68

Plan Deductible (In-Network)

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 9 of 68

Plan Deductible (Combined) – Base 1

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible (Combined) – Base 2

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible (Out-of-Network)

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Deductible (Non-Network)

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 13 of 68

Max Enrollee Cost Limit (In-Network)

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 14 of 68

CY 2019 PBP Data Entry System Screens

Max Enrollee Cost Limit (Combined) – Base 1

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 15 of 68

CY 2019 PBP Data Entry System Screens

Max Enrollee Cost Limit (Combined) – Base 2

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 16 of 68

Max Enrollee Cost Limit (Out-of-Network)

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Max Enrollee Cost Limit (Non-Network)

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 18 of 68

Max Plan Benefit Coverage

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 19 of 68

CY 2019 PBP Data Entry System Screens

Max Plan Benefit Coverage (Non-Network)

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 20 of 68

Plan Premium/Rebate Reduction

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 21 of 68

CY 2019 PBP Data Entry System Screens

MMP – Medicaid/plan covered cost sharing

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 22 of 68

PFFS Balance Billing

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 23 of 68

MSA Annual Deductible/Deposit

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 24 of 68

Notes

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2019 PBP Data Entry System Screens

Optional Supplemental – Management Screen

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2019 PBP Data Entry System Screens

Optional Supplemental – Label and Premium

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
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CY 2019 PBP Data Entry System Screens

Optional Supplemental – Service Categories

Fu Associates, Ltd.

CY2019 PBP – Section D
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Optional Supplemental – OON Optional

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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Optional Supplemental – OON Step-up

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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Page 30 of 68

CY 2019 PBP Data Entry System Screens

Step-up #7b Chiropractic Services – Base 1

Fu Associates, Ltd.

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2019 PBP Data Entry System Screens

Step-up #7b Chiropractic Services – Base 2

Fu Associates, Ltd.

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2019 PBP Data Entry System Screens

Step-up #7b Chiropractic Services – Base 3

Fu Associates, Ltd.

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #7f Podiatry Services – Base 1

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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Step-up #7f Podiatry Services – Base 2

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #7f Podiatry Services – Base 3

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 36 of 68

CY 2019 PBP Data Entry System Screens

Step-up #10b Transportation Services – Base 1

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 37 of 68

CY 2019 PBP Data Entry System Screens

Step-up #10b Transportation Services – Base 2

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 38 of 68

CY 2019 PBP Data Entry System Screens

Step-up #10b Transportation Services – Base 3

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 39 of 68

Step-up #16a Preventive Dental – Base 1

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #16a Preventive Dental – Base 2

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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Step-up #16a Preventive Dental – Base 3

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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Step-up #16a Preventive Dental – Base 4

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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Step-up #16a Preventive Dental – Base 5

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2019 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 1

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2019 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 2

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2019 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 3

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2019 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 4

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2019 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 5

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2019 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 6

Fu Associates, Ltd.

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17a Eye Exams – Base 1

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17a Eye Exams – Base 2

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17a Eye Exams – Base 3

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17b Eyewear – Base 1

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17b Eyewear – Base 2

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17b Eyewear – Base 3

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17b Eyewear – Base 4

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17b Eyewear – Base 5

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #17b Eyewear – Base 6

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #18a Hearing Exams – Base 1

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #18a Hearing Exams – Base 2

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #18a Hearing Exams – Base 3

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #18a Hearing Exams – Base 4

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #18b Hearing Aids – Base 1

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #18b Hearing Aids – Base 2

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #18b Hearing Aids – Base 3

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Step-up #18b Hearing Aids – Base 4

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 67 of 68

Step-up #18b Hearing Aids – Base 5

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

CY2019 PBP – Section D
11/17/2017
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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File Type	application/pdf
File Title	CY 2019 PBP Data Entry System Screens - Section D
Author	Scott Meyer
File Modified	2017-11-29
File Created	2017-11-29