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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.