CMS-R-262 Section Rx

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

Appendix_C_PBP2024 Section Rx

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⚠️ Notice: This form may be outdated.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

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Rx Setup – Page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Rx Setup – Page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
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Rx Setup – Page 3

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Rx Setup – Page 4

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Rx Cost Share – Page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
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Rx Cost Share – Page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
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Tier Locations – Page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
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Tier Locations – Page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
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Tier Locations – Page 3

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
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Tier Locations – Page 4

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
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CY 2024 PBP Data Entry System Screens

Tier Setup Screen (Sample for Tier 1 with Preferred Generic) - Page 1

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CY2024 PBP – Section Rx
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Tier Setup Screen (Sample for Tier 1 with Preferred Generic) - Page 2

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CY2024 PBP – Section Rx
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CY 2024 PBP Data Entry System Screens

Pre-ICL Tier Screen (Sample with Preferred Generic) – Page 1

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CY2024 PBP – Section Rx
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Pre-ICL Tier Screen (Sample with Preferred Generic) – Page 2

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CY2024 PBP – Section Rx
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Pre-ICL Tier Screen (Sample with Preferred Generic) – Page 3

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CY2024 PBP – Section Rx
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CY 2024 PBP Data Entry System Screens

GAP Tier Screen (Sample with Preferred Generic) – Page 1

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CY2024 PBP – Section Rx
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

GAP Tier Screen (Sample with Preferred Generic) – Page 2

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CY2024 PBP – Section Rx
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

GAP Tier Screen (Sample with Preferred Generic) – Page 3

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CY2024 PBP – Section Rx
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Post OOP Screen (Sample with Preferred Generic) – Page 1

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CY 2024 PBP Data Entry System Screens

Post OOP Screen (Sample with Preferred Generic) – Page 2

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CY2024 PBP – Section Rx
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Medicare Rx Attestations

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
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Rx Insulin

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – Section Rx
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CY 2024 PBP Data Entry System Screens

Rx Insulin Tier Screen (Sample with Tier 1 - Generic)

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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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Rx Notes

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File Type	application/pdf
File Title	CY 2024 PBP Data Entry System Screens
Author	Michelle Hsu
File Modified	2023-01-12
File Created	2023-01-12