CMS-R-262 CY 2019 PBP Data Entry System Screens - Section Rx (VBID

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_Rx_VBID_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⚠️ Notice: This form may be outdated.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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VBID – General

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 1 of 26

VBID – Package Setup

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 2 of 26

VBID – Package Tiers – Pre-ICL

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 3 of 26

VBID – Tier Coverage – Pre-ICL

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 4 of 26

VBID – Tier Locations – Pre-ICL

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 5 of 26

VBID – Retail Copayment – Pre-ICL

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 6 of 26

VBID – Retail Coinsurance – Pre-ICL

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 7 of 26

VBID – Mail Order Copayment – Pre-ICL

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 8 of 26

VBID – Mail Order Coinsurance – Pre-ICL

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 9 of 26

CY 2019 PBP Data Entry System Screens

VBID – Out-of-Network and LTC Cost Sharing – Pre-ICL

Fu Associates, Ltd.

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

Page 10 of 26

CY 2019 PBP Data Entry System Screens

VBID – Daily Retail and Mail Order Copay – Pre-ICL

Fu Associates, Ltd.

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

Page 11 of 26

VBID – Daily LTC Copay – Pre-ICL

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 12 of 26

VBID – Package Tiers – Gap

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 13 of 26

VBID – Tier coverage – Gap

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 14 of 26

VBID – Tier Locations – Gap

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 15 of 26

VBID – Retail Copayment – Gap

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 16 of 26

VBID – Retail Coinsurance – Gap

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 17 of 26

VBID – Mail Order Copayment – Gap

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 18 of 26

VBID – Mail Order Coinsurance – Gap

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 19 of 26

CY 2019 PBP Data Entry System Screens

VBID – Out-of-Network and LTC Cost Sharing – Gap

Fu Associates, Ltd.

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

Page 20 of 26

CY 2019 PBP Data Entry System Screens

VBID – Daily Retail and Mail Order Copay – Gap

Fu Associates, Ltd.

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

Page 21 of 26

VBID – Daily LTC Copay – Gap

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 22 of 26

VBID – Package Tiers – OOP Threshold

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 23 of 26

VBID – Tier Coverage – OOP Threshold

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 24 of 26

VBID – Post OOP Threshold Cost Sharing

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 25 of 26

VBID – Package notes

Fu Associates, Ltd.

CY 2019 PBP Data Entry System Screens

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

Page 26 of 26

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