CMS-R-262 VBID – General

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

Appendix_C_PBP2022-Screenshots-Section-Rx-VBID-09-16

CY2022 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⚠️ Notice: This form may be outdated.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:
Document [pdf]
Download: pdf | pdf
VBID – General

CY 2022 PBP Data Entry System Screens

Insert new
question - “Are
you offering Part
D Benefits under
the VBID Model?”

Softrams

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 1 of 29

VBID Part D Rewards and Incentives #1

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 2 of 29

VBID Part D Rewards and Incentives #2

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 3 of 29

VBID Part D Rewards and Incentives #3

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 4 of 29

CY 2022 PBP Data Entry System Screens
VBID – Package Setup

Softrams

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 5 of 29

VBID – Package Tiers – Pre-ICL

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 6 of 29

VBID – Tier Coverage – Pre-ICL

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 7 of 29

VBID – Tier Locations – Pre-ICL

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 8 of 29

VBID – Retail Copayment – Pre-ICL

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 9 of 29

VBID – Retail Coinsurance – Pre-ICL

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 10 of 29

VBID – Mail Order Copayment – Pre-ICL

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 11 of 29

VBID – Mail Order Coinsurance – Pre-ICL

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 12 of 29

CY 2022 PBP Data Entry System Screens

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

Softrams

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 13 of 29

CY 2022 PBP Data Entry System Screens

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

Softrams

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 14 of 29

VBID – Daily LTC Copay – Pre-ICL

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 15 of 29

VBID – Package Tiers – Gap

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 16 of 29

VBID – Tier Coverage – Gap

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 17 of 29

VBID – Tier Locations – Gap

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 18 of 29

VBID – Retail Copayment – Gap

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 19 of 29

VBID – Retail Coinsurance – Gap

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 20 of 29

VBID – Mail Order Copayment – Gap

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 21 of 29

VBID – Mail Order Coinsurance – Gap

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 22 of 29

CY 2022 PBP Data Entry System Screens

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

Softrams

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 23 of 29

CY 2022 PBP Data Entry System Screens

VBID – Daily Retail and Mail Order Copay – Gap

Softrams

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 24 of 29

VBID – Daily LTC Copay – Gap

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 25 of 29

VBID – Daily LTC Copay – Gap

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 26 of 29

VBID – Tier Coverage – OOP Threshold

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 27 of 29

VBID – Post OOP Threshold Cost Sharing

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 28 of 29

VBID – Package notes

Softrams

CY 2022 PBP Data Entry System Screens

CY2022 PBP – Section Rx VBID
09/16/2020
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 29 of 29
File Type	application/pdf
File Title	CY 2022 PBP Data Entry System Screens - Section Rx VBID
Author	CMS
File Modified	2020-10-14
File Created	2020-09-21