CMS-R-262 General Setup

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

Appendix_C_PBP2024 General Setup

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⚠️ Notice: This form may be outdated.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]
Download: pdf | pdf
Plan Benefit Package Landing Page

Softrams

CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Characteristics – page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Characteristics – page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Characteristics – page 3

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 4 of 40

Plan Characteristics – page 4

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Standard Bid

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Benefit Offerings - page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 7 of 40

Benefit Offerings - page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Benefit Offerings – Medicare Services – page 1

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CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 9 of 40

CY 2024 PBP Data Entry System Screens

Benefit Offerings – Medicare Services – page 2

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CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Benefit Offerings – Non-Medicare Services – page 1

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CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Benefit Offerings – Non Medicare Services – page 2

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CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Plan Level Cost Sharing – page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 13 of 40

Plan Level Cost Sharing – page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 14 of 40

Plan Level Cost Sharing – page 3

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 15 of 40

Plan Level Cost Sharing – page 4

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 16 of 40

Plan Level Cost Sharing – page 5

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 17 of 40

Plan Level Cost Sharing – page 6

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 18 of 40

Plan Level Cost Sharing – page 7

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 19 of 40

Plan Level Cost Sharing – page 8

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 20 of 40

Plan Level Cost Sharing – page 9

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 21 of 40

Plan Level Cost Sharing – page 10

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 22 of 40

Plan Level Cost Sharing – page 11

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 23 of 40

Plan Level Cost Sharing – page 12

Softrams

CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 24 of 40

Plan Level Cost Sharing – page 13

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 25 of 40

Plan Level Cost Sharing – page 14

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 26 of 40

CY 2024 PBP Data Entry System Screens

Annual Plan Deductible – Plan Specific (Sample Screen for LPPO/RPPO) – page 1

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CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Annual Plan Deductible – Plan Specific (Sample Screen for LPPO/RPPO)– page 2

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CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 28 of 40

CY 2024 PBP Data Entry System Screens

Annual Plan Deductible – Plan Specific (Sample Screen for LPPO/RPPO) – page 3

Softrams

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 29 of 40

CY 2024 PBP Data Entry System Screens

Differential Service Category Deductibles (Unique for LPPO/RPPO) – page 1

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CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 30 of 40

CY 2024 PBP Data Entry System Screens

Differential Service Category Deductibles (Unique for LPPO/RPPO) – page 2

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CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 31 of 40

CY 2024 PBP Data Entry System Screens

Differential for LPPO/RPPO Mandatory Supplemental Benefits (Unique for LPPO/RPPO) – page 1

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CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Differential for LPPO/RPPO Mandatory Supplemental Benefits (Unique for LPPO/RPPO) – page 1

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CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 33 of 40

CY 2024 PBP Data Entry System Screens

Max Enrollee Cost Limit - Plan Specific (Sample Screen for LPPO/RPPO)– page 1

Softrams

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 34 of 40

CY 2024 PBP Data Entry System Screens

Max Enrollee Cost Limit - Plan Specific (Sample Screen for LPPO/RPPO)– page 2

Softrams

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 35 of 40

CY 2024 PBP Data Entry System Screens

Max Enrollee Cost Limit - Plan Specific (Sample Screen for LPPO/RPPO)– page 3

Softrams

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 36 of 40

CY 2024 PBP Data Entry System Screens

Max Enrollee Cost Limit - Plan Specific (Sample Screen for LPPO/RPPO)– page 4

Softrams

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Prior Authorization/Referrals – page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 38 of 40

Prior Authorization/Referrals – page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 39 of 40

Visitor Travel – page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – General Setup
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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File Type	application/pdf
File Title	CY 2024 PBP Data Entry System Screens
Author	CMS
File Modified	2023-01-12
File Created	2022-08-31