Form CMS-10725 Transparency Attestation

OMB Control Number: 0938-NEW
Expiration Date: XX/XX/2023

Pharmacy Benefit Manager Transparency for Qualified Health Plans Attestation
Appendix D – Attestation
Section 1150A of the Social Security Act requires an entity that provides pharmacy benefit
management services on behalf of a health benefit plan that manages prescription drug coverage
under a contract with a Qualified Health Plan (QHP) offered through an Exchange report the
certain prescription drug and pharmacy benefit management financial data to the Centers for
Medicare and Medicaid Services (CMS). The official listed below, signing on behalf of
(“the PBM”), makes the following attestation
concerning the accompanying data reporting:
I attest that I am aware of what is included in the PBM’s data reporting. I attest on behalf of the
PBM (based on best knowledge, information, and belief), that the data submitted to CMS are
accurate, complete, and truthful.

Name of PBM

Printed Name of PBM Official Authorized to Sign

Date

Signature of PBM Official Authorized to Sign

Title/Position

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 193 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].