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pdfMedicare Rx General 1
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 1 of 71
Medicare Rx General 2
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 2 of 71
Medicare Rx General 3
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 3 of 71
CY 2021 PBP Data Entry System Screens
Medicare Rx – Tier Model (when a tier includes 2 tiers)
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 4 of 71
CY 2021 PBP Data Entry System Screens
Medicare Rx- Tier Model (when a tier includes 3 tiers)
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 5 of 71
CY 2021 PBP Data Entry System Screens
Medicare Rx – Tier Model (when a tier includes 4 tiers)
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 6 of 71
CY 2021 PBP Data Entry System Screens
Medicare Rx – Tier Model (when a tier includes 5 tiers)
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 7 of 71
CY 2021 PBP Data Entry System Screens
Medicare Rx – Tier Model (when a tier includes 6 tiers)
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 8 of 71
CY 2021 PBP Data Entry System Screens
Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 2 tiers)
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 9 of 71
CY 2021 PBP Data Entry System Screens
Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 3 tiers)
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 10 of 71
CY 2021 PBP Data Entry System Screens
Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 4 tiers)
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 11 of 71
CY 2021 PBP Data Entry System Screens
Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 5 tiers)
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 12 of 71
CY 2021 PBP Data Entry System Screens
Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 6 tiers)
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 13 of 71
CY 2021 PBP Data Entry System Screens
Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 7 tiers)
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 14 of 71
CY 2021 PBP Data Entry System Screens
Defined Standard – ICL and OOP Threshold
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 15 of 71
Actuarially Equivalent Characteristics
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 16 of 71
Actuarially Equivalent – Pre-ICL
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 17 of 71
CY 2021 PBP Data Entry System Screens
Actuarially Equivalent – Tier Type and Cost Share Structure – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 18 of 71
CY 2021 PBP Data Entry System Screens
Actuarially Equivalent – Tier Locations – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 19 of 71
CY 2021 PBP Data Entry System Screens
Actuarially Equivalent – Retail Pharmacy Location Supply – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 20 of 71
CY 2021 PBP Data Entry System Screens
Actuarially Equivalent – Mail Order Location Supply – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 21 of 71
CY 2021 PBP Data Entry System Screens
Actuarially Equivalent – OON and LTC Location Supply – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 22 of 71
CY 2021 PBP Data Entry System Screens
Actuarially Equivalent – Retail Pharmacy Copayment and Coinsurance – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 23 of 71
CY 2021 PBP Data Entry System Screens
Actuarially Equivalent – Mail Order Copayment and Coinsurance – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 24 of 71
CY 2021 PBP Data Entry System Screens
Actuarially Equivalent – OON and LTC Copayment and Coinsurance – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 25 of 71
CY 2021 PBP Data Entry System Screens
Actuarially Equivalent – Daily Copayment Amount Cost Sharing – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 26 of 71
Actuarially Equivalent – OOP Threshold
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 27 of 71
CY 2021 PBP Data Entry System Screens
Actuarially Equivalent – Tier Type – Post-OOP Threshold
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 28 of 71
CY 2021 PBP Data Entry System Screens
Actuarially Equivalent – Tier Cost Sharing – Post-OOP Threshold
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 29 of 71
Alternative – Deductible
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 30 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Enhanced Alternative Characteristics
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 31 of 71
Alternative – Pre-ICL
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 32 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Tier Type and Cost Share Structure – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 33 of 71
Alternative – Tier Locations – Pre-ICL
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 34 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Retail Pharmacy Location Supply – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 35 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Mail Order Location Supply – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 36 of 71
CY 2021 PBP Data Entry System Screens
Alternative – OON and LTC Location Supply – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 37 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Retail Pharmacy Copayment and Coinsurance – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 38 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Mail Order Copayment and Coinsurance – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 39 of 71
CY 2021 PBP Data Entry System Screens
Alternative – OON and LTC Copayment and Coinsurance – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 40 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Daily Copayment Amount Cost Sharing – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 41 of 71
Alternative – Pre-ICL Medicare-Medicaid
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 42 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Tier Type – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 43 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Tier Locations – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 44 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Retail Pharmacy Location Supply – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 45 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Mail Order Location Supply – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 46 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Medicare-Medicaid OON and LTC Location Supply – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 47 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Copayment – Pre-ICL
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 48 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Daily Copayment Amount Cost Sharing
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 49 of 71
Alternative – ICL
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 50 of 71
Alternative – Gap Coverage
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 51 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Tier Type and Cost Share Structure – Gap
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 52 of 71
Alternative – Tier Coverage – Gap
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 53 of 71
Alternative – Tier Locations – Gap
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 54 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Retail Pharmacy Location Supply – Gap
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 55 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Mail Order Location Supply – Gap
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 56 of 71
CY 2021 PBP Data Entry System Screens
Alternative – OON and LTC Location Supply – Gap
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 57 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Retail Pharmacy Copayment and Coinsurance – Gap
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 58 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Mail Order Copayment and Coinsurance – Gap
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 59 of 71
CY 2021 PBP Data Entry System Screens
Alternative – OON and LTC Copayment and Coinsurance – Gap
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 60 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Daily Copayment Amount Cost Sharing – Gap
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 61 of 71
Alternative – OOP Threshold
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 62 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Tier Type – Post-OOP Threshold
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 63 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Tier Cost Sharing Post-OOP Threshold
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 64 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Post-OOP Threshold
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 65 of 71
CY 2021 PBP Data Entry System Screens
Alternative – Tier Type and Tier Cost Sharing Post-OOP Medicare and Medicaid
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 66 of 71
CY 2021 PBP Data Entry System Screens
Defined Standard – Locations and Location Supply
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 67 of 71
Medicare Rx – Attestations
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 68 of 71
Medicare RX – Notes
Softrams
CY 2021 PBP Data Entry System Screens
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 69 of 71
CY 2021 PBP Data Entry System Screens
Part D Payment Modernization Benefit – Base 1
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 70 of 71
CY 2021 PBP Data Entry System Screens
Part D Payment Modernization Benefit – Base 2
Softrams
CY2021 PBP – Section Rx
12/09/2019
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 71 of 71
| File Type | application/pdf |
| File Title | CY 2021 PBP Data Entry System Screens |
| Author | Softrams |
| File Modified | 2019-12-10 |
| File Created | 2019-12-10 |