CMS-10725 Transparency Summary Web Form

OMB Control Number: 0938-NEW
Expiration Date: XX/XX/2023
PBM Transparency Collection Summary Data
Enter summary data for one Issuer in the boxes on the right side of this web form. Attach detailed plan
level data as a tab delimited text (.txt) file.

Data Element Name
Calendar Year
PBM Name
Issuer Name
Issuer State
Issuer HIOS ID
PBM Retained Rebates
PBM Retained Rebates (Additional Comments)
Rebates Expected But Not Yet Received
PBM Incentive Payments
All Other Rebates
All Other Rebates (Additional Comments)
Price Concessions for Administrative Services from Manufacturers
All Other Price Concessions from Manufacturers
All Other Price Concessions from Manufacturers (Additional
Comments)
Amounts Received from Pharmacies
Amounts Received from Pharmacies (Additional Comments)
Amounts Paid to Pharmacies
Amounts Paid to Pharmacies (Additional Comments)
PBM Spread Amounts for Retail Pharmacies
PBM Spread Amounts for Mail Order Pharmacies
Allocation Methodology for Issuer Level Data
Allocation Methodology for Issuer Level Data Comments
Allocation Methodology for 11-digit NDC Level Data
Allocation Methodology for 11-digit NDC Level Data Comments

Summary Data
2020
PBM Name
Issuer Name
DC
00000
$0
Text
$0
$0
$0
Text
$0
$0
Text
$0
Text
$0
Text
$0
$0
Dropdown
Text
Dropdown
Text

Attach tab delimited .txt file here:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-NEW (Expires XX/XX/2023). The time required to complete this information collection is
estimated to average 203.64 hours per response, including the time to review instructions, search existing data
resources, and gather the data needed, and complete the template and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or
any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact Ken Buerger at
[email protected], or LeAnn Brodhead at [email protected].