List of Changes (Crosswalk)

CY 2020 PBP/MTMP/Formulary List of Changes
CY 2020 PBP Changes
Landing Page
1. The PBP software landing page has been updated to reflect the CY 2020 year changes.
Source: Internal
PBP Screen/Category: Landing Page
Document: APPENDIX_C_PBP2020_Screenshots_SectionA_Upload_2018_12_12.pdf
Page(s): Page 9
Citation: 42 CFR 422.256
Reason why change is needed: To update the year reference throughout the software.
Impact to Burden: No impact
Section A
1. The PBP software has been updated to populate the referral questions for B1a, B1b, and B2
when standard bid is selected for Section B in Section A.
Source: Internal
PBP Screen/Category: Section A-5
Document: APPENDIX_C_PBP2020_Screenshots_SectionA_Upload_2018_12_12.pdf
Page(s): Page 5
Citation: 42 CFR 422.256
Reason why change is needed: To fix a problem with the CY2019 PBP population of standard bid
for these categories.
Impact to Burden: Lessens impact
Section B
1. The PBP software will be updated to include new Supervised Exercise Therapy (SET) for
Symptomatic Peripheral Artery Disease (PAD) SET for PAD Medicare and Non Medicare covered
services in Section B3. The on screen note from the CY 2019 PBP Software will be removed.
Source: CMS Policy
PBP Screen/Category: Section B3 Cardiac and Pulmonary Rehabilitation Services
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 48-51
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Low impact

2. The PBP software will be updated to include a new Medicare-covered B7j: Additional Telehealth
section. It will allow plan users to offer Additional Telehealth services for any Medicare-covered
benefit. Although it is a Medicare-covered benefit, it will be optional for plans.
Source: CMS Policy
PBP Screen/Category: Section B7j Additional Telehealth
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 94-96
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Medium impact
3. The PBP software has been updated to include a new Medicare-covered B7k: Opioid Treatment
Services section. It will be mandatory for plans.
Source: CMS Policy
PBP Screen/Category: Section B7k Opioid Treatment Services
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 97-98
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Medium impact
4. The PBP software has been updated to add to Rideshare Services to PBP category B10b
Transportation for Plan-approved Location and Any Health-related Location
Source: CMS Policy
PBP Screen/Category: B10b Transportation Services
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 120
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: No impact
5. The PBP software has been updated to allow SNP plans to select B14b Annual Physical Exam as a
supplemental benefit.
Source: CMS Policy
PBP Screen/Category: B14b Annual Physical Exam
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 187-189
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: No impact

6. The PBP software has been updated to change the name of Section B14c to "Other Defined
Supplemental Benefits"
Source: CMS Policy
PBP Screen/Category: Section 14c Other Defined Supplemental Benefits
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 190-204
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: No impact
7. The PBP software has been updated to include new supplemental benefits in 14c. They are
Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, In-Home Support
Services, and Support for Caregivers of Enrollees.
Source: CMS Policy
PBP Screen/Category: Section B19 VBID/UF/SSBCI
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 190-204
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Medium impact
8. The PBP software will be updated to make the “Other Medicare-covered preventive services”
benefit optional in Section B14e. A new N/A option is available in response to the authorization
question in this section. If the plan does not offer Other Medicare-covered preventive services,
they can choose N/A.
Source: CMS Policy
PBP Screen/Category: Section B14e Other Medicare-covered Preventive Services
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 210
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Lowers impact
9. The PBP software will be updated to include a new Step Therapy Question for Part B plans
offering a drug benefit in Section B15. The plan must then indicate if the benefit steps up in any
of the following ways: Part B to Part B, Part B to Part D, Part D to Part B.
Source: CMS Policy
PBP Screen/Category: Section B15 Medicare Part B Rx Drugs
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 213

Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Potential Low to no impact
10. The PBP software will be updated to include minimum and maximum coinsurance and
copayment range fields for office visits in Section B16a.
Source: Internal
PBP Screen/Category: Section B16a Preventive Dental Base 3 and Base 4
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_2018_12_12.pdf
Page(s): Page 218 and Page 219
Citation: 42 CFR 422.256
Reason why change is needed: Based on discussion after CMS review of bids for CY2019.
Impact to Burden: Low impact
11. The PBP software will be updated to include new questions regarding disease states for UF
plans. The questions are “Does the enrollee need to have all diseases selected to qualify? Y/N”
and “Does the enrollee have to have a combination of diseases selected to qualify? Y/N” will be
added for all packages in 19a and 19b.
Source: CMS Policy
PBP Screen/Category: Section 19a Reduced Cost Sharing for VBID/UF/SSBCI – Disease States: UF
and Section 19b Additional Benefits for VBID/UF- Disease States: UF
Document: APPENDIX_C_PBP2020_Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Page 5 and Page 63
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Low impact
12. The PBP software has been updated to include new VBID Interventions for selection in B19a and
B19b. They are Social Determinants of Health-based Supplemental Benefits, Medicare
Advantage Rewards and Incentives Programs, Wellness and Health Care Planning, Telehealth
Networks, and Medical Device Coverage.
Source: CMS Policy
PBP Screen/Category: Section 19 VBID/MA Uniformity Flexibility/SSBCI
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Page 1
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Low impact
13. The PBP software has been updated expand Section B19 to include the option to select Special
Supplemental Benefits for the Chronically Ill (SSBCI). All MA and SNP plans besides Cost plans

can offer SSBCI. Only one SSBCI package is allowed in 19a. Only one SSBCI package is allowed in
19b. SSBCI Packages do not select disease states.
Source: CMS Policy
PBP Screen/Category: Section B19 VBID/UF/SSBCI
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Pages 1, 3, and 61
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Low impact
14. The PBP software has been updated to include a new benefit for plans offering Special
Supplemental Benefits for the Chronically Ill (SSBCI) in Section B19b. They will have the ability
to select new 13i Non-Primarily Health Related Benefits for the Chronically Ill. That section
includes Home-Delivered Meals (beyond limited basis), Transportation for Non-Medical Needs,
Food and Produce, Pest Control, and three other categories to be defined by the plan.
Source: CMS Policy
PBP Screen/Category: Section 19b Additional Benefits for VBID/UF/SSBCI
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Pages 65 and 139-160
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Medium impact
15. The PBP software will be updated to remove restrictions on which Supplemental Benefits can be
included in a 19b package for UF plans. All UF plans will now be able to offer 14c Health
Education, 14c Medical Nutrition Therapy, and 14c Enhanced Disease Management. C-SNP
plans will still be prevented from offering Enhanced Disease Management.
Source: CMS Policy
PBP Screen/Category: Section 19b Additional Benefits for VBID/UF
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Page 164
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Low impact
16. Section B19b of the PBP software will be updated to change the text of the question “Is there a
maximum aggregate amount of reduced cost sharing?” to “Is there a maximum benefit
amount?”
Source: CMS Policy

PBP Screen/Category: Section 19b Additional Benefits for VBID/UF – Base 3 (Retroactive
Reimbursement)
Document: APPENDIX_C_PBP2020_ Screenshots_SectionB_VBID_UF_SSBCI_2018_12_12.pdf
Page(s): Page 67
Citation: 42 CFR 422.256
Reason why change is needed: To clarify the question in the PBP
Impact to Burden: No impact
Section D
1. The PBP software has been updated to reflect the CY2020 year change in the Section D
LPPO/RPPO deductible instructions.
Source: Internal
PBP Screen/Category: Section D: Plan Deductible
Document: APPENDIX_C_PBP2020_ Screenshots_SectionD_2018_12_12.pdf
Page(s): Page 1
Citation: 42 CFR 422.256
Reason why change is needed: To update the year references throughout the software.
Impact to Burden: No impact
2. The PBP software has been updated to require all EGWP plans, except for MSA EGWP Plans, to
enter responses to “Are you using any of your plan’s MA rebates to reduce the Part B
Premium?” and “Indicate the Part B Premium reduction amount:" premium amounts in Section
D since they do not submit a BPT with their bid.
Source: CMS Policy
PBP Screen/Category: Section D Plan Premium/Rebate Reduction
Document: APPENDIX_C_PBP2020_ Screenshots_SectionD_2018_12_12.pdf
Page(s): Page 21
Citation: 42 CFR 422.256
Reason why change is needed: To address regulatory changes in CMS policy.
Impact to Burden: Low impact

Section Rx
1. The PBP software will be updated to include the following new question regarding indication
based coverage: “Will your plan be limiting on-formulary coverage of drugs to certain
indications (i.e., are you implementing indication-based formulary design)?”
Source: CMS Policy
PBP Screen/Category: Section Rx, Medicare Rx General Screen 2
Document: APPENDIX_C_PBP2020_ Screenshots_SectionRx_2018_12_12.pdf
Page(s): Page 2

Citation: HPMS Memorandum “Indication-Based Formulary Design Beginning in Contract Year
(CY) 2020”, dated August 29, 2018
Reason why change is needed: To address new CMS Policy.
Impact to Burden: Low impact
2. The PBP software will be updated to include new guidance on entering Out-of-Network cost
sharing in Section Rx.
Source: CMS Policy
PBP Screen/Category: Section Rx, Actuarially Equivalent Characteristics Screen and AlternativeDeductible Screen
Document: APPENDIX_C_PBP2020_ Screenshots_SectionRx_2018_12_12.pdf
Page(s): Page 15 and 29
Citation: 42 CFR 422.256
Reason why change is needed: To clarify existing CMS policy.
Impact to Burden: No impact

CY 2020 MTMP Changes
1. There is a requirement to update the Verify Submission page to display the following message:
“Your data will not be submitted until you click the “Submit’ button at the bottom of the page”
Source: Internal
MTMP Screen/Category: CY 2020 MTMP - Enter/Edit Verify Submission Page
Document: Appendix_C_MTMP CY2020 Enhancements Mockups.pdf
Page(s): Page 1
Citation: Lessons learned
Reason why change is needed: To meet the business needs
Impact to Burden: No impact

CY 2020 Formulary Changes
1. CMS will be collecting a new Indication-Based Coverage Supplemental File. This file will be
submitted only by plans that specify they are providing indication-based coverage on the
formulary. The submission will include the affected RxCUIs and the applicable indication
code(s). CMS will provide a reference file of indication-based coverage codes.
Source: Internal
Formulary Screen/Category: Indication-Based Coverage File Record Layout
Document: Appendix_C_Formulary_IndicationBasedCoverage_Record_Layout.pdf
Page(s): Page 1
Citation: 42 CFR 423.120

Reason why change is needed: In order to allow plans to implement the formulary design that
was announced in the August 29, 2018 HPMS memorandum titled “Indication-Based Formulary
Design Beginning in Contract Year (CY) 2020”
Impact to Burden: Low impact

2. CMS has updated the layout for the Opioid Strategy submission. Some questions were removed
or clarified and additional questions or details were added to some sections to provide more
clear instructions to Sponsors.
Source: Internal
Formulary Screen/Category: Opioid Strategy Layout
Document: Appendix_C_CY2020_Formulary_Opioid Strategy Layout
Pages(s): Page 1-3
Citation: 42 CFR 423.120
Reason why change is needed: The changes were made as a result of CMS’ review of the CY2019
submissions.
Impact to Burden: No impact
3. CMS has updated the Excluded Drug file layout. The NDC field has been replaced with RxCUI.
Source: Internal
Formulary Screen/Category: Excluded Drugs File Record Layout
Document: Appendix_C_CY2020_EXC_Record_Layout
Pages(s): Page 1
Citation: 42 CFR 423.120
Reason why change is needed: The changes were made to reduce the burden for sponsors and
streamline CMS’ review of the files.
Impact to Burden: Lessens impact
4. CMS has updated the Prior Authorization File Layout. These two new fields have been added:
PA_Indication_Indicator: This field must be populated with one of the values below. This field is used to
describe the indications for which the PA will be approved.
1 = All FDA-approved Indications. This value cannot be used if the drug that requires PA is
subject to Indication-Based Coverage (IBC).
2 = Some FDA-approved Indications Only. This value is to be submitted for drugs that are subject
to IBC.
3 = All Medically-accepted Indications. Drugs for which the PA will be approved for all Part D
medically-accepted indications (FDA-approved and compendia-supported) should be submitted
with a 3.

4 = All FDA-approved Indications, Some Medically-accepted Indications. If the PA will only be
approved for specific off-label uses, a 4 should be submitted. The additional off-label uses
should be submitted in the subsequent Off-Label Uses field.
Off-label_Uses:
o CHAR Required only if a 4 is entered for PA_Indication_Indicator
o Max length = 3000
o Enter the specific off-label uses for which the PA will be approved. This field must not
contain any FDA-approved indications.
Source: Internal
Formulary Screen/Category: Prior Authorization File Layout
Document: Appendix_C_CY2020_PA_Record_Layout
Pages(s): Page 1-2
Citation: 42 CFR 423.120
Reason why change is needed: The changes were made to collect data for the new indication
based coverage data.
Impact to Burden: Low Impact.
5. CMS has created a new PA/ST change request file layout.
Source: Internal
Formulary Screen/Category: PA/ST Criteria Change Request Record Layout
Document: Appendix_C_CY2020_PAST_Criteria_Change_Request_Record_Layout
Pages(s): Page 1-2
Citation: 42 CFR 423.120
Reason why change is needed: The change is being made to make the PA/ST update process
more efficient for plans.
Impact to Burden: Lessens impact