Information Collection

PBM - Annual Submission of Prescription Benefit Information

IC 243637 under ICR 202009-0938-009 · OMB 0938-1394.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1394 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10725 PBM - Annual Submission of Prescription Benefit Information Form and Instruction
CMS-10725 - Appendix C PBM Transparency Submission Instructions.pdf Instruction
CMS-10725 - Appendix C PBM Transparency Submission Instructions.pdf Instruction
CMS-10725 Transparency Summary Web Form CMS-10725 - Appendix A PBM Transparency Summary Web Form.pdf Form and Instruction
CMS-10725 Transparency Summary Web Form CMS-10725 - Appendix A PBM Transparency Summary Web Form.pdf Form and Instruction
CMs-10725 Transparency Detailed Template CMS-10725 - Appendix B PBM Transparency Detailed Template.pdf Form
CMs-10725 Transparency Detailed Template CMS-10725 - Appendix B PBM Transparency Detailed Template.pdf Form
CMS-10725 Transparency Attestation CMS-10725 -Appendix D PBM Transparency Attestation.pdf Form and Instruction
CMS-10725 Transparency Attestation CMS-10725 -Appendix D PBM Transparency Attestation.pdf Form and Instruction
CMS-10725 QHP Issuer Transparency Attestation CMS-10725 - Appendix E QHP Issuer Transparency Attestation.pdf Form and Instruction
CMS-10725 QHP Issuer Transparency Attestation CMS-10725 - Appendix E QHP Issuer Transparency Attestation.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	PBM - Annual Submission of Prescription Benefit Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10725	Transparency Summary Web Form	CMS-10725 - Appendix A PBM Transparency Summary Web Form.pdf	Yes	Yes	Fillable Fileable
Form	CMs-10725	Transparency Detailed Template	CMS-10725 - Appendix B PBM Transparency Detailed Template.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS-10725 - Appendix C PBM Transparency Submission Instructions.pdf	Yes	No	Paper Only
Form and Instruction	CMS-10725	Transparency Attestation	CMS-10725 -Appendix D PBM Transparency Attestation.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10725	QHP Issuer Transparency Attestation	CMS-10725 - Appendix E QHP Issuer Transparency Attestation.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	1,278	1,278
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.