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_PBP2025 Cost Share Groups

OMB: 0938-0763

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Out-of-Network (OON) Groups Setup

Softrams

CY 2025 PBP Data Entry System Screens

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 1 of 23

CY 2025 PBP Data Entry System Screens

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

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 2 of 23

CY 2025 PBP Data Entry System Screens

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

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 3 of 23

Point of Service (POS) Groups Setup

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CY 2025 PBP Data Entry System Screens

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 4 of 23

CY 2025 PBP Data Entry System Screens

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

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 5 of 23

CY 2025 PBP Data Entry System Screens

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

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 6 of 23

CY 2025 PBP Data Entry System Screens

Combined Supplemental Benefits Group Setup

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 7 of 23

CY 2025 PBP Data Entry System Screens

Combined Supplemental Benefits – Add New Group – Page 1

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CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 8 of 23

CY 2025 PBP Data Entry System Screens

Combined Supplemental Benefits – Add New Group – Page 2

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 9 of 23

CY 2025 PBP Data Entry System Screens

Reduction in Cost Sharing (RICS) Groups Setup

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 10 of 23

CY 2025 PBP Data Entry System Screens

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

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 11 of 23

CY 2025 PBP Data Entry System Screens

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

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 12 of 23

CY 2025 PBP Data Entry System Screens

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

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 13 of 23

CY 2025 PBP Data Entry System Screens

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

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 14 of 23

Optional Supplemental Packages Setup

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CY 2025 PBP Data Entry System Screens

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 15 of 23

CY 2025 PBP Data Entry System Screens

Optional Supplemental Packages – Add New Package – Page 1

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 16 of 23

CY 2025 PBP Data Entry System Screens

Optional Supplemental Packages – Add New Package – Page 2

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 17 of 23

CY 2025 PBP Data Entry System Screens

Optional Supplemental Packages – Add New Package – Page 3

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 18 of 23

CY 2025 PBP Data Entry System Screens

Optional Supplemental Packages – Add Package with Service 4c (sample) - Page 1

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 19 of 23

CY 2025 PBP Data Entry System Screens

Optional Supplemental Packages – Add Package with Service 4c (sample) – Page 2

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 20 of 23

CY 2025 PBP Data Entry System Screens

Optional Supplemental Packages – Add Package with Service 4c2 (sample) - Page 1

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 21 of 23

CY 2025 PBP Data Entry System Screens

Optional Supplemental Packages – Add Package with Service 4c2 (sample) - Page 2

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 22 of 23

CY 2025 PBP Data Entry System Screens

Optional Supplemental Packages – Add Package with Service 4c2 (sample) - Page 3

Softrams

CY2025 PBP – Cost Share Groups
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 23 of 23
File Type	application/pdf
File Title	CY 2025 PBP Data Entry System Screens
Author	CMS
File Modified	2023-12-18
File Created	2023-12-18