CMS-R-262 OON – General – Base 1

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

Appendix_C_PBP2023-Screenshots-SectionC-2021-12-27

OMB: 0938-0763

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OON – General – Base 1

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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OON – General – Base 2

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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OON – General – Notes

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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OON – Inpatient – Base 1

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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OON – Inpatient – Base 2

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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OON – Inpatient – Base 3

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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OON – Inpatient – Base 4

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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OON – SNF – Base 1

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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OON – SNF – Base 2

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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OON – Number of Groups

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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OON – Groups – Base 1

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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OON – Groups – Base 2

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – General – Base 1

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – General – Base 2

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – General – Base 3

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – General – Base 4

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – General – Base 5

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – General – Base 6

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – Inpatient – Base 1

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – Inpatient – Base 2

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – Inpatient – Base 3

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 21 of 29

POS – Inpatient – Base 4

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 22 of 29

POS – Inpatient – Base 5

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 23 of 29

POS – SNF – Base 1

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – SNF – Base 2

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 25 of 29

POS – Number of Groups

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – Groups – Base 1

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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POS – Groups – Base 2

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 28 of 29

V/T – General – US

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CY 2023 PBP Data Entry System Screens

CY2023 PBP – Section C
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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File Typeapplication/pdf
File TitleCY 2023 PBP Data Entry System Screens - Section C
AuthorCMS
File Modified2021-12-15
File Created2021-12-15

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