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pdfMedicare Rx General 1
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CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 1 of 78
Medicare Rx General 2
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CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 2 of 78
Medicare Rx General 3
Softrams
CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 3 of 78
CY 2023 PBP Data Entry System Screens
Medicare Rx – Tier Model (when a tier includes 2 tiers)
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CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 4 of 78
CY 2023 PBP Data Entry System Screens
Medicare Rx- Tier Model (when a tier includes 3 tiers)
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CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 5 of 78
CY 2023 PBP Data Entry System Screens
Medicare Rx – Tier Model (when a tier includes 4 tiers)
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 6 of 78
CY 2023 PBP Data Entry System Screens
Medicare Rx – Tier Model (when a tier includes 5 tiers)
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CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 7 of 78
CY 2023 PBP Data Entry System Screens
Medicare Rx – Tier Model (when a tier includes 7 tiers)
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CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 8 of 78
CY 2023 PBP Data Entry System Screens
Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 2 tiers)
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 9 of 78
CY 2023 PBP Data Entry System Screens
Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 3 tiers)
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 10 of 78
CY 2023 PBP Data Entry System Screens
Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 4 tiers)
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 11 of 78
CY 2023 PBP Data Entry System Screens
Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 5 tiers)
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 12 of 78
CY 2023 PBP Data Entry System Screens
Medicare Rx – Medicare-Medicaid Formulary Tier Model (when a tier includes 6 tiers)
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 13 of 78
CY 2023 PBP Data Entry System Screens
Defined Standard – ICL and OOP Threshold
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 14 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent Characteristics
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CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 15 of 78
Actuarially Equivalent – Pre-ICL
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CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 16 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent – Tier Type and Cost Share Structure – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 17 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent – Tier Locations – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 18 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent – Retail Pharmacy Location Supply – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 19 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent – Mail Order Location Supply – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 20 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent – OON and LTC Location Supply – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 21 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent – Retail Pharmacy Copayment and Coinsurance – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 22 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent – Mail Order Copayment and Coinsurance – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 23 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent – OON and LTC Copayment and Coinsurance – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 24 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent – Daily Copayment Amount Cost Sharing – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 25 of 78
Actuarially Equivalent – OOP Threshold
Softrams
CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 26 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent – Tier Type – Post-OOP Threshold
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 27 of 78
CY 2023 PBP Data Entry System Screens
Actuarially Equivalent – Tier Cost Sharing – Post-OOP Threshold
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 28 of 78
Alternative – Deductible
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CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 29 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Enhanced Alternative Characteristics
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 30 of 78
Alternative – Pre-ICL
Softrams
CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 31 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Tier Type and Cost Share Structure – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 32 of 78
Alternative – Tier Locations – Pre-ICL
Softrams
CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 33 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Retail Pharmacy Location Supply – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 34 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Mail Order Location Supply – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 35 of 78
CY 2023 PBP Data Entry System Screens
Alternative – OON and LTC Location Supply – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 36 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Retail Pharmacy Copayment and Coinsurance – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 37 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Mail Order Copayment and Coinsurance – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 38 of 78
CY 2023 PBP Data Entry System Screens
Alternative – OON and LTC Copayment and Coinsurance – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 39 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Daily Copayment Amount Cost Sharing – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 40 of 78
Alternative – Pre-ICL Medicare-Medicaid
Softrams
CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 41 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Tier Type – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 42 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Tier Locations – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 43 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Retail Pharmacy Location Supply – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 44 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Mail Order Location Supply – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 45 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Medicare-Medicaid OON and LTC Location Supply – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 46 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Copayment – Pre-ICL
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 47 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Daily Copayment Amount Cost Sharing
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 48 of 78
Alternative – ICL
Softrams
CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 49 of 78
Alternative – Gap Coverage
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CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 50 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Tier Type and Cost Share Structure – Gap
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 51 of 78
Alternative – Tier Coverage – Gap
Softrams
CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 52 of 78
Alternative – Tier Locations – Gap
Softrams
CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 53 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Retail Pharmacy Location Supply – Gap
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 54 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Mail-Order Location Supply – Gap
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 55 of 78
CY 2023 PBP Data Entry System Screens
Alternative – OON and LTC Location Supply – Gap
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 56 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Retail Pharmacy Copayment and Coinsurance – Gap
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 57 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Mail Order Copayment and Coinsurance – Gap
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 58 of 78
CY 2023 PBP Data Entry System Screens
Alternative – OON and LTC Copayment and Coinsurance – Gap
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 59 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Daily Copayment Amount Cost Sharing – Gap
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 60 of 78
Alternative – OOP Threshold
Softrams
CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 61 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Tier Type – Post-OOP Threshold
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 62 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Tier Cost Sharing Post-OOP Threshold
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 63 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Medicare-Medicaid Post-OOP Threshold
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 64 of 78
CY 2023 PBP Data Entry System Screens
Alternative – Tier Type and Tier Cost Sharing Post-OOP Medicare and Medicaid
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 65 of 78
CY 2023 PBP Data Entry System Screens
Defined Standard – Locations and Location Supply
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 66 of 78
Medicare Rx – Attestations
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CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 67 of 78
Medicare RX – Notes
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CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 68 of 78
CY 2023 PBP Data Entry System Screens
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 69 of 78
CY 2023 PBP Data Entry System Screens
Part D Senior Savings Model Benefit – General
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 70 of 78
Part D Senior Savings Model Benefit #1
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CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 71 of 78
Part D Senior Savings Model Benefit #2
Softrams
CY 2023 PBP Data Entry System Screens
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 72 of 78
CY 2023 PBP Data Entry System Screens
Part D Senior Savings Model Benefit – Cost Sharing General
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 73 of 78
CY 2023 PBP Data Entry System Screens
Part D Senior Savings Model Benefit – Cost Sharing Cohort 1
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 74 of 78
CY 2023 PBP Data Entry System Screens
Part D Senior Savings Model Benefit – Cost Sharing Cohort 2
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 75 of 78
CY 2023 PBP Data Entry System Screens
Part D Senior Savings Model Benefit – Cost Sharing Cohort 3
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 76 of 78
CY 2023 PBP Data Entry System Screens
Part D Senior Savings Model Benefit – Cost Sharing Cohort 4
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 77 of 78
CY 2023 PBP Data Entry System Screens
Part D Senior Savings Model Benefit – Cost Sharing Cohort 5
Softrams
CY2023 PBP – Section Rx
12/27/2021
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 78 of 78
| File Type | application/pdf |
| File Title | CY 2023 PBP Data Entry System Screens - Section Rx |
| Author | CMS |
| File Modified | 2021-12-21 |
| File Created | 2021-12-20 |