Crosswalk (30-day)

CY 2026 List of Changes – 30 Day PRA Package
CY 2026 PBP Changes
Overall
1. Date references throughout PBP pages and screens are updated to reflect the CY 2026 year. 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 software.
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. Service Category 13a “Acupuncture – Number of Treatments” in Non-Medicare Services has been
changed to “Acupuncture Treatments”.
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: Service category renamed.
IMPACT BURDEN: No Impact
3. The checkbox for “Three (3) pint Deductible Waived (9d)” is being removed from the Benefit
Offerings Non-Medicare Services page and from benefit picklists throughout PBP. A 3-pint
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
1.

Add to OON Group functionality and Out-of-Network (OON) Group screens are being removed.
OON cost sharing questions will be moved to Benefit Details screens. Point-of-Service (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 typo
IMPACT BURDEN: No Impact
Benefit Details
1. Add to OON Group functionality is being removed from Benefit Details screens. OON groups will
no longer exist and OON cost sharing questions will be moved to 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, Appendix_C_PBP2026
Benefit Details - Service Categories 11-15, and Appendix_C_PBP2026 Benefit Details - Service
Categories 16-20.
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): 80- 87
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), an on-screen note is being
added to 8a and 8b to remind plans not to enter preventive services in these categories as follows
“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): 158 and page 167
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): 201
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Simplify data entry
IMPACT BURDEN: Reduces Burden
5. Service Category 13a: “Acupuncture – Number of Treatments” in Non-Medicare Services is being
changed to “Acupuncture Treatments”.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Acupuncture Treatments (13a)
DOCUMENT: Appendix_C_PBP2026 Benefit Details - Service Categories 11-15
PAGE(S): 26 - 31
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Service category renamed.
IMPACT BURDEN: No Impact
6. 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 should be enabled for the user to
enter the description of other. Limit text to 200 characters
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Over-the Counter (OTC) Items (13b)

DOCUMENT: Appendix_C_PBP2026 Benefit Details - Service Categories 11-15
PAGE(S): 34
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Provide information on mode of delivery for plans
IMPACT BURDEN: Low Impact
7. In 14c7, separate notes fields are being added for Web/Phone-based technologies and Nursing
Hotline. A note is required for Web/Phone-based technologies. The note is optional for 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 11-15
PAGE(S): Page 98
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Clarify data entry
IMPACT BURDEN: Low Impact
8. The character limit for maximum plan benefit coverage, Maximum enrollee out-of-pocket cost,
and benefit unlimited “Other, Describe” periodicity fields have been increased from 200 to 300
characters.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: All
DOCUMENT: Appendix_C_PBP2026 Benefit Details - Service Categories 1-10, Appendix_C_PBP2026
Benefit Details - Service Categories 11-15, and Appendix_C_PBP2026 Benefit Details - Service
Categories 16-20.
PAGE(S): Throughout
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Allow additional detail.
IMPACT BURDEN: No Impact
VBID-UF-SSBCI
1. The VBID Model will not be applicable for CY2026.
2.
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): 1
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: Clarify SSBCI details
IMPACT BURDEN: No Impact
4. For SSBCI Reduction in Cost Sharing and Additional Benefits packages, the list of chronic conditions
to select is being updated to be consistent with 42 CFR 422.2 Severe or disabling chronic conditions.
Source: CMS Policy

PBP SCREEN/CATEGORY: SSBCI Reduction in Cost Sharing Packages and Additional Benefits Packages
DOCUMENT: Appendix_C_PBP2026 VBID-UF-SSBCI Packages.pdf
PAGE(S): 27
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: policy update
IMPACT BURDEN: No Impact
5. For 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): 3, 4, 9, and 27
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 back 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?” and
a ‘Description’ field will enable if the user answers “yes” that a combination of diseases is needed
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): 4
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 MA UF and SSBCI Additional Benefits Packages, description fields for plans to define other
benefits for 13d,13e and 13f, separate from the plan’s mandatory supplemental benefits are being
added.
Source: CMS Policy
PBP SCREEN/CATEGORY: Additional Benefits Packages (13d, 13e, and 13f)
DOCUMENT: Appendix_C_PBP2026 VBID-UF-SSBCI Packages.pdf
PAGE(S): 38
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: policy requirement
IMPACT BURDEN: Low Impact
8. For SSBCI Additional Benefits Packages, the following additional questions are being added to
collect additional 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): 41 and 42
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: collect additional detail on covered benefits
IMPACT BURDEN: Low Impact
Section Rx
1. Part D plans offering 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
2. 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
3. When 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)” onscreen text above the Notes box will display as
follows “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

4. 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
5. 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
6. On the Rx Insulin screen, an attestation is being added and plans will be required to attest that
they comply with 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): 21
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: policy requirement
IMPACT BURDEN: No Impact
7. Coinsurance fields are being added to the applicable DS and Insulin Tier Screens.
SOURCE: CMS Policy
PBP SCREEN/CATEGORY: Rx Insulin Tier Screens
DOCUMENT: Appendix_C_PBP2026 Section Rx.pdf
PAGE(S): 22-24
CITATION: 42 CFR 422.256
REASON WHY CHANGE IS NEEDED: allow plans to allow coinsurance cost sharing for Rx Insulin Tiers
IMPACT BURDEN: No Impact
8. The Daily Copayment 1-month fields in each Tier screen will be auto-calculated based on location
supply and copayment values entered and will not be able to be modified 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: Consistent with the Daily Cost Sharing Rate, defined in CFR
423.100
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 action plan)" to
“Individualized, written summary of CMR in CMS’ standardized format (includes beneficiary
cover letter, recommended to-do list, and medication action plan).”

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): 1-3
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