CMS-R-262 Section Rx

CMS Plan Benefit Package (PBP) and Formulary CY 2026 (CMS-R-262) - IRA

Appendix_C_PBP2026 Section Rx

CY2026 Plan Benefit Package (PBP) Software and Formulary Submission

OMB: 0938-0763

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CY 2026 PBP Data Entry System Screens
Rx Setup – Page 1

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Rx Setup – Page 2

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 2 of 24

CY 2026 PBP Data Entry System Screens
Rx Setup – Page 3

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 3 of 24

CY 2026 PBP Data Entry System Screens
Rx Setup – Page 4

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 4 of 24

CY 2026 PBP Data Entry System Screens
Rx Cost Share – Page 1

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Rx Cost Share – Page 2

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 6 of 24

CY 2026 PBP Data Entry System Screens
Rx Cost Share – Page 3

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 7 of 24

CY 2026 PBP Data Entry System Screens
Tier Locations – Page 1

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CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Tier Locations – Page 2

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 9 of 24

CY 2026 PBP Data Entry System Screens
Tier Locations – Page 3

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 10 of 24

CY 2026 PBP Data Entry System Screens
Tier Locations – Page 4

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 11 of 24

CY 2026 PBP Data Entry System Screens
Tier Setup Screen (Sample for Tier 1 with Preferred Generic)

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Initial Coverage Phase Screen (Sample for Tier 1 with Preferred Generic) – Page 1

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Initial Coverage Phase Screen (Sample for Tier 1 with Preferred Generic) – Page 2

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 14 of 24

CY 2026 PBP Data Entry System Screens
Initial Coverage Phase Screen (Sample for Tier 1 with Preferred Generic) – Page 3

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 15 of 24

CY 2026 PBP Data Entry System Screens
Initial Coverage Phase Screen (Sample for Tier 1 with Preferred Generic) – Page 4

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Post OOP Screen (Sample for Tier 1 with Preferred Generic)

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Medicare Rx Attestations

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CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Defined Standard – Locations and Location Supply

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CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Rx Notes

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CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Rx Insulin

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CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Rx Insulin Tier Screen (Sample for Tier 3 – Specialty Tier) – Page 1

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
Rx Insulin Tier Screen (Sample for Tier 3 – Specialty Tier) – Page 2

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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CY 2026 PBP Data Entry System Screens
DS Insulin Cost Share

Softrams

CY2026 PBP – Section Rx
01/08/2025
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 24 of 24


File Typeapplication/pdf
File TitleCY 2026 PBP Data Entry System Screens
AuthorCMS
File Modified2025-01-03
File Created2025-01-03

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