CMS-R-262 Plan Deductible LPPO/RPPO 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-SectionD-2019-12-09

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

OMB: 0938-0763

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Plan Deductible LPPO/RPPO Base 1

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Plan Deductible LPPO/RPPO Base 2

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Plan Deductible LPPO/RPPO Base 3

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Plan Deductible LPPO/RPPO Base 4

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Plan Deductible LPPO/RPPO Base 5

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Plan Deductible LPPO/RPPO Base 6

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Deductible for LPPO/RPPO Mandatory Supplemental Benefits – Base 1

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CY 2021 PBP Data Entry System Screens

Deductible for LPPO/RPPO Mandatory Supplemental Benefits – Base 2

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CY2021 PBP – Section D
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Plan Deductible (In-Network)

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Plan Deductible (Combined) – Base 1

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Plan Deductible (Combined) – Base 2

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Plan Deductible (Out-of-Network)

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Plan Deductible (Non-Network)

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Max Enrollee Cost Limit (In-Network)

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Max Enrollee Cost Limit (Combined) – Base 1

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CY 2021 PBP Data Entry System Screens

Max Enrollee Cost Limit (Combined) – Base 2

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CY2021 PBP – Section D
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Max Enrollee Cost Limit (Out-of-Network)

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Max Enrollee Cost Limit (Non-Network)

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Max Plan Benefit Coverage

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Max Plan Benefit Coverage (Non-Network)

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CY2021 PBP – Section D
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Plan Premium/Rebate Reduction

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

MMP – Medicaid/plan covered cost sharing

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CY2021 PBP – Section D
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PFFS Balance Billing

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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MSA Annual Deductible/Deposit

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Reductions in Cost Sharing #1 – Base 1

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Reductions in Cost Sharing #1 – Base 2

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Reductions in Cost Sharing #2 – Base 1

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Reductions in Cost Sharing #2 – Base 2

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Reductions in Cost Sharing #3 – Base 1

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Reductions in Cost Sharing #3 – Base 2

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Combined Benefits #1

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CY2021 PBP – Section D
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Combined Benefits #2

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Combined Benefits #3

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Notes

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CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Optional Supplemental – Management Screen

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CY 2021 PBP Data Entry System Screens

Optional Supplemental – Label and Premium

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CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Optional Supplemental – Service Categories

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CY2021 PBP – Section D
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Optional Supplemental – OON Step-up

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Optional Supplemental – OON Optional

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Step-up #10b Transportation Services – Base 1

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CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Step-up #10b Transportation Services – Base 2

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CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Step-up #10b Transportation Services – Base 3

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CY2021 PBP – Section D
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Step-up #16a Preventive Dental – Base 1

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #16a Preventive Dental – Base 2

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #16a Preventive Dental – Base 3

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #16a Preventive Dental – Base 4

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #16a Preventive Dental – Base 5

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 1

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CY 2021 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 2

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CY 2021 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 3

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CY 2021 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 4

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CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 5

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CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Step-up #16b Comprehensive Dental – Base 6

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CY2021 PBP – Section D
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Step-Up #17a Eye Exams – Base 1

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-Up #17a Eye Exams – Base 2

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-Up #17a Eye Exams – Base 3

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #17b Eyewear – Base 1

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #17b Eyewear – Base 2

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #17b Eyewear – Base 3

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #17b Eyewear – Base 4

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #17b Eyewear – Base 5

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #17b Eyewear – Base 6

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #18a Hearing Exams – Base 1

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #18a Hearing Exams – Base 2

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #18a Hearing Exams – Base 3

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #18a Hearing Exams – Base 4

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #18b Hearing Aids -Base 1

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #18b Hearing Aids -Base 2

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CY2021 PBP – Section D
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Step-up #18b Hearing Aids -Base 3

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CY2021 PBP – Section D
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Step-up #18b Hearing Aids -Base 4

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CY2021 PBP – Section D
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Step-up #18b Hearing Aids -Base 5

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CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Step-up #7b Chiropractic Services – Base 1

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CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Step-up #7b Chiropractic Services – Base 2

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CY2021 PBP – Section D
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CY 2021 PBP Data Entry System Screens

Step-up #7b Chiropractic Services – Base 3

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CY2021 PBP – Section D
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Step-up #7f Podiatry Services – Base 1

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CY 2021 PBP Data Entry System Screens

CY2021 PBP – Section D
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Step-up #7f Podiatry Services – Base 2

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CY2021 PBP – Section D
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Step-up #7f Podiatry Services – Base 3

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File Typeapplication/pdf
File TitleCY 2021 PBP Data Entry System Screens
AuthorSoftrams
File Modified2019-12-09
File Created2019-12-09

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