Crosswalk (60-day)

Contract Year (CY) 2026 List of Changes – 60 Day PRA Package
CY 2026 PBP Changes
Overall
1. Date references throughout PBP pages and screens are updated to reflect CY 2026. Bid
submission and formulary-related due dates will be updated to reflect CY 2026 deadlines,
where appropriate.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: All
DOCUMENT: All
PAGE(S): All
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To update the year references and bid-related deadlines
throughout the module.
IMPACT BURDEN: No Impact
General Setup / Benefit Offerings / Plan Level Cost Sharing
1. The checkbox for “Service Category 5: Partial Hospitalization” is being removed from the
Benefit Offerings Medicare Services page, and is being renamed “Partial
Hospitalization/Intensive Outpatient Services.” Service Category 5 will be split into Partial
Hospitalization (5a) and Intensive Outpatient Services (5b) with checkboxes added for 5a and
5b.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Benefit Offerings – Medicare Services
DOCUMENT: Appendix_C_PBP2026_General Setup.pdf
PAGE(S): 7
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Further clarify benefit offerings.
IMPACT BURDEN: Low Impact
2. The checkbox for “Three (3) pint Deductible Waived (9d)” is being removed from both the
Benefit Offerings Non-Medicare Services page and benefit picklists throughout the PBP. A 3pint deductible waived question “Do you waive the deductible for the first three pints of
blood?” is being added under Benefit Details 9d.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Benefit Offerings – Non-Medicare Services
DOCUMENT: Appendix_C_PBP2026_General Setup.pdf
PAGE(S): 8
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Simplify data entry.
IMPACT BURDEN: Reduces Burden
Cost Share Groups
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1. The Add to OON Group functionality and Out-of-Network (OON) Group screens are being
removed. OON cost sharing questions will be moved to the Benefit Details screens. Point-ofService (POS) Groups will remain in place.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: OON Groups
DOCUMENT: Appendix_C_PBP2026_Cost Share Groups
PAGE(S): NA
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Simplify data entry.
IMPACT BURDEN: Reduces Burden
2. The acronym for Reductions in Costs Sharing is being corrected to say “RICS.”
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: RICS Groups
DOCUMENT: Appendix_C_PBP2026_Cost Share Groups
PAGE(S): 7
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Correct typographical error.
IMPACT BURDEN: No Impact
Benefit Details
1. The Add to OON Group functionality is being removed from the Benefit Details screens. OON
groups will no longer exist, and OON cost sharing questions will be moved to the Benefit Details
screens for any benefits that can be offered out of network. POS Groups will remain in place.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Benefit Details: Service Categories with OON benefits
DOCUMENT: Appendix_C_PBP2026 Benefit Details - Service Categories 1-10 and
Appendix_C_PBP2026 Benefit Details - Service Categories 11-20
PAGE(S): All
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Allow for greater flexibility in OON benefit offerings.
IMPACT BURDEN: Reduces Burden
2. Service Category 5: Partial Hospitalization will be split into 5a and 5b and will include separate
cost sharing data fields for Partial Hospitalization (5a) and Intensive Outpatient Services (5b).
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Partial Hospitalization/Intensive Outpatient Services (5)
DOCUMENT: Appendix_C_PBP2026 Benefit Details - Service Categories 1-10
PAGE(S): 67- 69
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Allow users to separate cost sharing data entry.
IMPACT BURDEN: Low Impact
3. Within Outpatient Procedures, Tests, Labs, and Radiology Services (8), the following on-screen
note is being added to 8a and 8b to remind plans not to enter preventive services in these
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categories: “Ensure the cost sharing range does not include cost sharing for Medicare-covered
preventive services that are included in 14a and 14e.”
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Outpatient Procedures, Tests, Labs and Radiology Services (8)
DOCUMENT: Appendix_C_PBP2026 Benefit Details - Service Categories 1-10
PAGE(S): 127 and page 133
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Improve data quality.
IMPACT BURDEN: No Impact
4. A 3-pint deductible waived question is being added to Benefit Details 9d page as follows: “Do you
waive the deductible for the first three pints of blood?”
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Outpatient Blood Services (9d)
DOCUMENT: Appendix_C_PBP2026 Benefit Details - Service Categories 1-10
PAGE(S): 155
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Simplify data entry.
IMPACT BURDEN: Reduces Burden
5. The question "Indicate mode of delivery for the OTC Items" is being added to 13b: OTC Benefit
Details with the following response options: Catalogue Purchase; Claims Processing; Debit Card;
Reimbursement; Other. If the user selects “Other,” then a text box will be enabled for the user to
enter the description of other. Text will be limited to 200 characters.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Over-the Counter (OTC) Items (13b)
DOCUMENT: Appendix_C_PBP2026 Benefit Details - Service Categories 11-20
PAGE(S): 29
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Provide plans with information on mode of delivery.
IMPACT BURDEN: Low Impact
6. In 14c7, separate notes fields are being added for Web/Phone-based technologies and Nursing
Hotline.

SOURCE: CMS Policy
PBP SCREEN/CATEGORY: 14c7- Remote Access Technologies (including Web/Phone-based
technologies and Nursing Hotline
DOCUMENT: Appendix_C_PBP2026 Benefit Details - Service Categories 11-20
PAGE(S): Page 117
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Clarify data entry.
IMPACT BURDEN: Low Impact
7. Within Diagnostic and Preventive Dental Services (16b) and Comprehensive Dental Services
(16c), the character limit for all periodicity description fields is being increased to 300
characters.
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SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Preventive Dental Services (16b) and Comprehensive Dental Services (16c)
DOCUMENT: Appendix_C_PBP2026 Benefit Details - Service Categories 11-20
PAGE(S): Page 193 - 227
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Allow additional detail.
IMPACT BURDEN: No Impact
VBID-UF-SSBCI
1. VBID Hospice questions, screens, and related text have been eliminated.
Source: CMS Policy
PBP SCREEN/CATEGORY: VBID, MA Uniformity, SSCBI Package Selection
DOCUMENT: Appendix_C_PBP2026 VBID-UF-SSBCI Packages.pdf
PAGE(S): 1
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: VBID Hospice is no longer part of VBID.
IMPACT BURDEN: No Impact
2. The language in the VBID Part C Attestation is being updated to remove “MA” from “MA-VBID”.
Source: CMS Policy
PBP SCREEN/CATEGORY: VBID, MA Uniformity, SSCBI Package Selection
DOCUMENT: Appendix_C_PBP2026 VBID-UF-SSBCI Packages.pdf
PAGE(S): 1 and 2
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Clarify language.
IMPACT BURDEN: No Impact
3. Updated language related to SSBCI will be added to the Package Selection page.
Source: CMS Policy
PBP SCREEN/CATEGORY: VBID, MA Uniformity, SSCBI Package Selection
DOCUMENT: Appendix_C_PBP2026 VBID-UF-SSBCI Packages.pdf
PAGE(S): 2
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Clarify SSBCI details.
IMPACT BURDEN: No Impact
4. For VBID and SSBCI Reduction in Cost Sharing and Additional Benefits packages, the list of disease
states/chronic conditions is being updated to be consistent with 42 CFR 422.2 Severe or disabling
chronic conditions.
Source: CMS Policy
PBP SCREEN/CATEGORY: VBID and SSBCI Reduction in Cost Sharing Packages and Additional
Benefits Packages
DOCUMENT: Appendix_C_PBP2026 VBID-UF-SSBCI Packages.pdf
PAGE(S): 4,5, 17, 36, and 37
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Policy update.
IMPACT BURDEN: No Impact
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5. For VBID, MA UF, and SSBCI Reduction in Cost Sharing and Additional Benefits packages, the field
limit to describe all “Other" chronic conditions/disease states (Other 1, Other 2, Other 3, Other 4,
and Other 5) is being expanded to 100 characters.
Source: CMS Policy
PBP SCREEN/CATEGORY: Reduction in Cost Sharing Packages
DOCUMENT: Appendix_C_PBP2026 VBID-UF-SSBCI Packages.pdf
PAGE(S): 12 and 17
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To provide more flexibility in describing disease states/chronic
conditions.
IMPACT BURDEN: No Impact
6. For MA UF Reduction in Cost Sharing and Additional Benefits packages, the following questions
are being added to the screens: “Does the enrollee need to have a combination of diseases
selected to qualify?” and “Does the enrollee need to have all diseases selected to qualify?”
Source: CMS Policy
PBP SCREEN/CATEGORY: Reduction in Cost Sharing Packages and Additional Benefits Packages
DOCUMENT: Appendix_C_PBP2026 VBID-UF-SSBCI Packages.pdf
PAGE(S): 12
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To be consistent with other packages and prior years.
IMPACT BURDEN: Low Impact
7. For VBID and MA UF Additional Benefits Packages, fields are being added so that plans can define
other benefits for 13d, 13e, and 13f, separate from the plan’s mandatory supplemental benefits.
Source: CMS Policy
PBP SCREEN/CATEGORY: Additional Benefits Packages (13d, 13e, and 13f)
DOCUMENT: Appendix_C_PBP2026 VBID-UF-SSBCI Packages.pdf
PAGE(S): 50
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Policy requirement.
IMPACT BURDEN: Low Impact
8. For VBID and SSBCI Additional Benefits Packages, the following questions are being added to
collect information on covered benefits in 13i10: General Supports for Living: "Are you offering
housing support such as rent or mortgage assistance as a covered benefit under General
Supports for Living?" "Are you offering utilities assistance as a covered benefit under General
Supports for Living?"
Source: CMS Policy
PBP SCREEN/CATEGORY: Additional Benefits Packages (VBID and SSBCI) (13i10)
DOCUMENT: Appendix_C_PBP2026 VBID-UF-SSBCI Packages.pdf
PAGE(S): 51
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To collect additional detail on covered benefits.
IMPACT BURDEN: Low Impact
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Section Rx
1. Platino plans will be able to offer an enhanced alternative (EA) drug benefit type in Rx Setup in
response to the “Select the type of drug benefit” question.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Rx Setup
DOCUMENT: Appendix_C_PBP2026 Section Rx.pdf
PAGE(S): 1
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Policy update.
IMPACT BURDEN: No Impact
2. Part D plans offering the EA drug benefit type will be able to designate a single tier formulary
structure. The question “Number of tiers in the Part D benefit” will include an option to
indicate 1 tier.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Rx Setup
DOCUMENT: Appendix_C_PBP2026 Section Rx.pdf
PAGE(S): 2 and 3
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Policy update.
IMPACT BURDEN: No Impact
3. The response options to the question "Indicate the area(s) throughout the Part D benefit where
the increase in actuarial value of benefits is reflected (select all that apply)” will be updated to
include "Deductible waived for at least one tier."
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Rx Cost Share
DOCUMENT: Appendix_C_PBP2026 Section Rx.pdf
PAGE(S): 5
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Policy update.
IMPACT BURDEN: No Impact
4. When a user selects “Reduced Initial Coverage Phase cost shares” in response to the question
"Indicate the area(s) throughout the Part D benefit where the increase in actuarial value of
benefits is reflected (select all that apply),” the PBP will display the following onscreen text
above the Notes box: “With respect to reduced Initial Coverage Phase cost shares, describe
how this plan fulfills the requirements to increase the actuarial value of benefits above the
actuarial value of defined standard prescription drug coverage, consistent with 42 CFR
423.104(f)()(ii)(B)(2):”
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Rx Cost Share
DOCUMENT: Appendix_C_PBP2026 Section Rx.pdf
PAGE(S): 5
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Clarify on screen instruction.
IMPACT BURDEN: No Impact
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5. The question “Indicate the Out-of-Network (OON) cost sharing structure for this plan” will be
revised to “Indicate the Out-of-Network (OON) cost sharing structure for this plan (note: must
comply with statutory requirements for covered insulins, ACIP-recommended adult vaccines,
catastrophic claims, and selected drugs).”
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Rx Cost Share
DOCUMENT: Appendix_C_PBP2026 Section Rx.pdf
PAGE(S): 6 and 7
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Clarify policy requirement.
IMPACT BURDEN: No Impact
6. Response options to the question “For excluded drugs only, how does this plan apply cost
sharing beyond the Medicare Part D Annual Out-of-Pocket threshold?” will be updated to
include:
• No cost sharing,
• Cost-Share Tiers (Same Cost sharing as the ICP), and
• Cost-Share Tiers (Different cost sharing than the ICP).
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Rx Cost Share
DOCUMENT: Appendix_C_PBP2026 Section Rx.pdf
PAGE(S): 7
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Simplify data entry.
IMPACT BURDEN: Reduces Impact
7. On the Rx Insulin screen, an attestation is being added, and plans will be required to attest that
they comply with the IRA 2026 cost sharing requirement for insulins: the lesser of $35, 25% of
MFP (for selected insulins) or 25% negotiated price (for non-selected insulins).
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Rx Insulin
DOCUMENT: Appendix_C_PBP2026 Section Rx.pdf
PAGE(S): 20
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Policy requirement.
IMPACT BURDEN: No Impact
8. Coinsurance fields are being added to the Rx Insulin Tier Screens.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Rx Insulin Tier Screens
DOCUMENT: Appendix_C_PBP2026 Section Rx.pdf
PAGE(S): 21 and 22
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Allow plans to allow coinsurance cost sharing for Rx insulin tiers.
IMPACT BURDEN: Low Impact

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9. The Daily Copayment 1-month fields in each tier screen will be auto-calculated based on the
location supply and copayment values entered and will not be editable by the user.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Insulin Coverage Phase Screen
DOCUMENT: Appendix_C_PBP2026 Section Rx.pdf
PAGE(S): 13-16
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To be consistent with the Daily Cost Sharing Rate, defined in
CFR 423.100.
IMPACT BURDEN: Reduces Impact
Section Rx – VBID
1. A VBID attestation is being added to the Rx VBID Setup Screen. Plans will attest that benefits
entered comply with the VBID model.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Rx VBID Setup
DOCUMENT: Appendix_C_PBP2026 VBID Rx.pdf
PAGE(S): 1
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Provide attestation for plans offering Rx VBID.
IMPACT BURDEN: No Impact
2.

A VBID attestation for Rewards and Incentives is being added to the Rx VBID Setup Screen.

SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Rx VBID Setup
DOCUMENT: Appendix_C_PBP2026 VBID Rx.pdf
PAGE(S): 1
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Provide attestation for plans offering Rx VBID Rewards and
Incentives.
IMPACT BURDEN: No Impact
3. For Rx VBID Reduced Cost Sharing, the following questions are being added to the screens:
“Does the enrollee need to have a combination of diseases selected to qualify?” and “Does the
enrollee need to have all diseases selected to qualify?”
Source: CMS Policy
PBP SCREEN/CATEGORY:
DOCUMENT: Appendix_C_PBP2026 VBID Rx.pdf
PAGE(S): 6 and 10
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: To be consistent with other packages.
IMPACT BURDEN: Low Impact

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4. For Rx VBID Reduced Cost Sharing, the list of chronic conditions/disease states is being updated
to be consistent with 42 CFR 422.2 Severe or disabling chronic conditions.
Source: CMS Policy
PBP SCREEN/CATEGORY: VBID and SSBCI Reduction in Cost Sharing Packages and Additional
Benefits Packages
DOCUMENT: Appendix_C_PBP2026 VBID Rx.pdf
PAGE(S): 6 and 10
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Policy update.
IMPACT BURDEN: No Impact

Formulary Changes
1. Adding the Prerequisite_Therapy_Required field to the Prior Authorization File Record
Layout.
Source: Internal
Formulary SCREEN/CATEGORY: N/A
DOCUMENT: Appendix_C_CY2026_PA_Record_Layout.pdf
PAGE(S): 2
CITATION: Lessons learned
REASON WHY CHANGE IS NEEDED: To improve transparency with respect to prior authorization
criteria.
IMPACT BURDEN: Low impact for plans; reduces impact for providers

MTMP Changes
1. On the Multiple Covered Part D Drugs page, if "All Part D maintenance drugs" is selected, adding
another selection to collect the database being used by the plan (Medi-Span, First Databank, or
Other - Fill In).
SOURCE: Internal
PBP SCREEN/CATEGORY: MTM Start Page
DOCUMENT: Appendix_C_MTM_Screenshots_for_PRA.pdf
PAGE(S): 1
CITATION: Lessons Learned
REASON WHY CHANGE IS NEEDED: Updates to MTM requirements for submission of database
collection type methods.
IMPACT BURDEN: Low Impact
2. On the Interventions page, a plan user will be required to enter interventions based on the following
text changes:
a. Change "Interactive, in-person or synchronous telehealth consultation" to "Interactive, inperson or synchronous telehealth consultation conducted in real-time."
b. Change "Individualized, written summary of CMR in CMS’ standardized format (includes
beneficiary cover letter, recommended to-do list, and personal medication list)" to
“Individualized, written summary of CMR in CMS’ standardized format (includes beneficiary
cover letter, recommended to-do list, and medication action plan).”
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c. Add language to [ ] Alternative language translations. After translations, add “(Plan sponsors
must provide translated materials when the 5 percent language threshold under 42 CFR §
423.2267(a)(2) has been reached.)”
SOURCE: Internal
PBP SCREEN/CATEGORY: Interventions Page
DOCUMENT: Appendix_C_MTM_Screenshots_for_PRA.pdf
PAGE(S): 1
CITATION: Lessons Learned
REASON WHY CHANGE IS NEEDED: To clarify and ensure requirements are met.
IMPACT BURDEN: No Impact
3. On all submission pages, provide the ability for plan users to save data on the MTM submission. Add
a save button to each page of the submission process. On the last submission page, the submit
button will remain.
SOURCE: Internal
PBP SCREEN/CATEGORY: All Submission pages
DOCUMENT: Appendix_C_MTM_Screenshots_for_PRA.pdf
PAGE(S): various
CITATION: Lessons Learned
REASON WHY CHANGE IS NEEDED: Update better serves users.
IMPACT BURDEN: No Impact

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