CMS-R-262 VBID-UF-SSBCI Packages

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

Appendix_C_PBP2024 VBID-UF-SSBCI Packages

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⚠️ Notice: This form may be outdated.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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CY 2024 PBP Data Entry System Screens

VBID, MA Uniformity, SSCBI Package Selection – Page 1

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

VBID, MA Uniformity, SSCBI Package Selection – Page 2

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

VBID Wellness and Health Care Planning (WHP) – Page 1

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CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

VBID Wellness and Health Care Planning (WHP) – Page 2

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CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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VBID Hospice – Page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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VBID Hospice – Page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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VBID Hospice – Page 3

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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VBID Hospice – Page 4

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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VBID Hospice – Page 5

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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VBID Rewards and Incentives – Page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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VBID Rewards and Incentives – Page 2

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages (VBID/MA UF/SSBCI)

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID) – Page 1

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CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID) – Page 2

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CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID) – Page 3

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (SSBCI) – Page 1

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (SSBCI) – Page 2

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (MA UF) – Page 1

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (MA UF) – Page 2

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 1

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 2

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 3

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 4

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 5

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 6

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 7

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 8

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 9

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 28 of 49

CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 10

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 29 of 49

CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 11

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 30 of 49

CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 12

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 31 of 49

CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 13

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 32 of 49

CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 14

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 33 of 49

CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 15

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 34 of 49

CY 2024 PBP Data Entry System Screens

Reduction in Cost Sharing Packages – Add Package (VBID/MA UF/SSBCI) Continued – Page 16

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 35 of 49

CY 2024 PBP Data Entry System Screens

Additional Benefits Packages (VBID/MA UF/SSBCI)

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 36 of 49

CY 2024 PBP Data Entry System Screens

Additional Benefits Packages – Add Package (VBID/MA UF/SSBCI) – VBID Example – Page 1

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Additional Benefits Packages – Add Package (VBID/MA UF/SSBCI) – VBID Example – Page 2

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Additional Benefits Packages – Add Package (VBID/MA UF/SSBCI) – VBID Example – Page 3

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Additional Benefits Packages – Add Package (VBID/MA UF/SSBCI) – VBID Example – Page 4

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Additional Benefits Packages – Add Package (VBID/MA UF/SSBCI) – VBID Example – Page 5

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 41 of 49

CY 2024 PBP Data Entry System Screens

Additional Benefits Packages – Add Package (VBID/MA UF/SSBCI) – VBID Example – Page 6

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Additional Benefits Packages –Selected Benefit Screen (Routine Chiropractic Care Example – 7b1) - Page 1

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Additional Benefits Packages –Selected Benefit Screen (Sample Screen for Routine Chiropractic Care – 7b1) - Page 2

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Additional Benefits Packages –Selected Benefit Screen (Sample Screen for Transportation Services - 10b1) - Page 1

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2024 PBP Data Entry System Screens

Additional Benefits Packages –Selected Benefit Screen (Sample Screen for Transportation Services - 10b1) - Page 2

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 46 of 49

CY 2024 PBP Data Entry System Screens

Additional Benefits Packages –Selected Benefit Screen (Sample Screen for Transportation Services - 10b1) - Page 3

Softrams

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 47 of 49

VBID Health Equity Plan (HEP) – Page 1

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CY 2024 PBP Data Entry System Screens

CY2024 PBP – VBID-UF-SSBCI Packages
01/13/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 48 of 49

VBID Health Equity Plan (HEP) – Page 2

Softrams

CY 2024 PBP Data Entry System Screens

CY2024 PBP – VBID-UF-SSBCI Packages
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	Michelle Hsu
File Modified	2023-01-12
File Created	2023-01-12