CMS-R-262 Cost Share Groups

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

Appendix_C_PBP2024 Cost Share Groups

OMB: 0938-0763

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0763 can be found here:
2024-01-25 - Revision of a currently approved collection
Document [pdf]
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CY 2024 PBP Data Entry System Screens

Cost Share Groups – Out of Network Groups

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 1 of 24

CY 2024 PBP Data Entry System Screens

Out of Network Groups – Add New OON Group – page 1

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 2 of 24

CY 2024 PBP Data Entry System Screens

Out of Network Groups – Add New OON Group – page 2

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 3 of 24

CY 2024 PBP Data Entry System Screens

Out of Network Groups – Edit Out of Network Group – page 1

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 4 of 24

CY 2024 PBP Data Entry System Screens

Out of Network Groups – Edit Out of Network Group – page 2

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 5 of 24

CY 2024 PBP Data Entry System Screens

Out of Network Groups – Edit Out of Network Group – page 3

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 6 of 24

CY 2024 PBP Data Entry System Screens

Cost Share Groups – Point of Service (POS) Groups

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 7 of 24

CY 2024 PBP Data Entry System Screens

Point of Service Groups – Add New POS Group – page 1

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 8 of 24

CY 2024 PBP Data Entry System Screens

Point of Service Groups – Add New POS Group – page 2

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 9 of 24

CY 2024 PBP Data Entry System Screens

Cost Share Groups – Combined Supplemental Benefits

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 10 of 24

CY 2024 PBP Data Entry System Screens

Combined Supplemental Benefits – Add New Combined Benefits Group – page 1

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 11 of 24

CY 2024 PBP Data Entry System Screens

Combined Supplemental Benefits – Add New Combined Benefits Group – page 2

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 12 of 24

CY 2024 PBP Data Entry System Screens

Cost Share Groups – Reduction in Cost Sharing (RICS) Groups

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 13 of 24

CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing – Add New RICS Group – page 1

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 14 of 24

CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing – Add New RICS Group – page 2

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 15 of 24

CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing – Add New RICS Group – page 3

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 16 of 24

CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing – Add New RICS Group – page 4

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 17 of 24

CY 2024 PBP Data Entry System Screens

Cost Share Groups – Optional Supplemental Packages

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 18 of 24

CY 2024 PBP Data Entry System Screens

Optional Supplemental Packages – Add New Package – page 1

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 19 of 24

CY 2024 PBP Data Entry System Screens

Optional Supplemental Packages – Add New Package – page 2

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 20 of 24

CY 2024 PBP Data Entry System Screens

Optional Supplemental Packages – Add New Package – page 3

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 21 of 24

CY 2024 PBP Data Entry System Screens

Optional Supplemental Packages– Edit Package – page 1

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 22 of 24

CY 2024 PBP Data Entry System Screens

Optional Supplemental Packages – Edit Package – page 2

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 23 of 24

CY 2024 PBP Data Entry System Screens

Optional Supplemental Packages – Edit Package – page 3

Softrams

CY2024 PBP – Cost Share Groups
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 24 of 24
File Type	application/pdf
File Title	CY 2024 PBP Data Entry System Screens
Author	Michelle Hsu
File Modified	2023-01-09
File Created	2023-01-09