CMS-R-262 #1a Inpatient Hospital-Acute – Base 1

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

Appendix_C_PBP2021_Screenshots-SectionB-2019-12-09

CY2021 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

OMB: 0938-0763

Document [pdf]
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#1a Inpatient Hospital-Acute – Base 1

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#7d Physician Specialist Services – Base 1

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#7k Opioid Treatment Program Services – Base 1

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#9d Outpatient Blood Services – Base 1

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#10a Ambulance Services – Base 1

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#10a Ambulance Services – Base 2

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CY 2021 PBP Data Entry System Screens

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#10b Transportation Services – Base 1

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#10b Transportation Services – Base 2

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CY 2021 PBP Data Entry System Screens

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#10b Transportation Services – Base 3

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CY 2021 PBP Data Entry System Screens

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#11a DME – Base 1

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CY 2021 PBP Data Entry System Screens

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#11a DME – Base 2

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CY 2021 PBP Data Entry System Screens

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#11a DME – MMP – Base 1

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CY 2021 PBP Data Entry System Screens

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#11a DME – MMP – Base 2

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CY 2021 PBP Data Entry System Screens

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CY 2021 PBP Data Entry System Screens

#11b Prosthetics/Medical Supplies – Base 1

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#11c Diabetic Supplies and Services – Base 1

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#11c Diabetic Supplies and Services – Base 2

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#12 Dialysis Services – Base 1

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#12 Dialysis Services – Base 2

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#13a Acupuncture – Base 1

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CY 2021 PBP Data Entry System Screens

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CY 2021 PBP Data Entry System Screens

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CY 2021 PBP Data Entry System Screens

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#13b OTC Items – Base 1

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CY 2021 PBP Data Entry System Screens

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CY 2021 PBP Data Entry System Screens

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CY 2021 PBP Data Entry System Screens

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#13c Meal Benefit – Base 1

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CY 2021 PBP Data Entry System Screens

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CY 2021 PBP Data Entry System Screens

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CY 2021 PBP Data Entry System Screens

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CY 2021 PBP Data Entry System Screens

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#13g Dual Eligible SNPs with Highly Integrated Services – Base 1

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#13h Additional Services – Base 1

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#14a Medicare-covered Zero Dollar Preventive Services

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#14b Annual Physical Exam – Base 1

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#14c Other Defined Supplemental Benefits – Base 1

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#14c Other Defined Supplemental Benefits – Base 6

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#14c Other Defined Supplemental Benefits – Base 7

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#14c Other Defined Supplemental Benefits – Base 9

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#14c Other Defined Supplemental Benefits – Base 11

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#14c Other Defined Supplemental Benefits – Base 12

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#14c Other Defined Supplemental Benefits – Base 14

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#14c Other Defined Supplemental Benefits – Base 15

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#14d Kidney Disease Education Services Base 1

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#14d Kidney Disease Education Services Base 2

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#14d Kidney Disease Education Services – Base 3

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#14e Other Medicare-covered Preventive Services – Base 1

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#15 Medicare Part B Rx Drugs – Base 1

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#15 Medicare Part B Rx Drugs – Notes

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#15 Home Infusion Bundled Services

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File Typeapplication/pdf
File TitleCY 2021 PBP Data Entry System Screens
AuthorSoftrams
File Modified2019-12-10
File Created2019-12-10

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