Form CMS-10846 HPMS Data Entry Fields

Appendix A. Part D Manufacturer Discount Program Data Entry Fields in HPMS
†

Data element required for the Discount Program.

* If the manufacturer populates the main data field, these fields must be populated.
Contract Information
Data Element
†
P Number

Field Notes
Unique identifier established by CMS for each
Manufacturer.

†

Manufacturer Name
DUNS Number
†
Employer Identification Number (EIN)*
†

†

Additional EIN

†

Manufacturer Address

The EIN is used to generate any IRS Form 1099s
associated with this P number, if applicable.
If applicable, enter each additional EIN for this P
number not already entered in the prior EIN field.
Do not enter EINs for other P numbers belonging
to the same controlled group. One or more
occurrences permitted.
This must a U.S. address. Manufacturers have the
option to also include an international address.

†

Address 1
Address 2
†
City/Town/Locality
†
State
†
Zip Code
†
Primary Contact
Primary Contact Prefix
†
Primary Contact First
Primary Contact MI
†
Primary Contact Last
Primary Contact Title
†
Primary Contact Phone
Primary Contact Ext.
Primary Contact Alternate Phone
Primary Contact Alt. Ext.
Primary Contact Fax
†
Primary Contact Email
†
Primary Contact Address

Address for primary contact must be a U.S.
address.

†

Primary Contact City
Primary Contact State
†
Primary Contact Zip
Secondary Contact
Secondary Contact Prefix
*Secondary Contact First
Secondary Contact MI
†

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Contract Information
Data Element
*Secondary Contact Last
Secondary Contact Title
*Secondary Contact Phone
Secondary Contact Ext.
Secondary Contact Alternate Phone
Secondary Contact Alt. Ext.
Secondary Contact Fax
*Secondary Contact Email
*Secondary Contact Address
*Secondary Contact City
*Secondary Contact State
*Secondary Contact Zip
†
Signatory Contact

Field Notes

Signatory contact must be (1) the chief executive
officer (CEO), (2) the chief financial officer (CFO),
(3) an individual other than a CEO or CFO, who has
authority equivalent to a CEO or a CFO, or (4) an
individual with the directly delegated authority to
sign on behalf of one of the individuals mentioned
in (1) through (3).

Signatory Contact Prefix
†
Signatory Contact First
Signatory Contact MI
†
Signatory Contact Last
Signatory Contact Title
†
Signatory Contact Phone
Signatory Contact Ext.
Signatory Contact Alternate Phone
Signatory Contact Alt. Ext.
Signatory Contact Fax
†
Signatory Contact Email
†
Signatory Contact Address
†
Signatory Contact City
†
Signatory Contact State
†
Signatory Contact Zip
Secondary Signatory Contact
Secondary Signatory Contact Prefix
*Secondary Signatory Contact First
Secondary Signatory Contact MI
*Secondary Signatory Contact Last
Secondary Signatory Contact Title
*Secondary Signatory Contact Phone
Secondary Signatory Contact Ext.
Secondary Signatory Contact Alternate Phone
Secondary Signatory Contact Alt. Ext.
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Contract Information
Data Element
Secondary Signatory Contact Fax
*Secondary Signatory Contact Email
*Secondary Signatory Contact Address
*Secondary Signatory Contact City
*Secondary Signatory Contact State
*Secondary Signatory Contact Zip
†
TPA Liaison Contact
TPA Liaison Contact Prefix
†
TPA Liaison Contact First
TPA Liaison Contact MI
†
TPA Liaison Contact Last
TPA Liaison Contact Title
†
TPA Liaison Contact Phone
TPA Liaison Contact Ext.
TPA Liaison Contact Alternate Phone
TPA Liaison Contact Alt. Ext.
TPA Liaison Contact Fax
†
TPA Liaison Contact Email
†
TPA Liaison Contact Address
†
TPA Liaison Contact City
†
TPA Liaison Contact State
†
TPA Liaison Contact Zip
†
Payment Contact
Payment Contact Prefix
†
Payment Contact First
Payment Contact MI
†
Payment Contact Last
Payment Contact Title
†
Payment Contact Phone
Payment Contact Ext.
Payment Contact Alternate Phone
Payment Contact Alt. Ext.
Payment Contact Fax
†
Payment Contact Email
†
Payment Contact Address
†
Payment Contact City
†
Payment Contact State
†
Payment Contact Zip
†
Senior Product Contact
Senior Product Contact Prefix
†
Senior Product Contact First
Senior Product Contact MI
†
Senior Product Contact Last
Senior Product Contact Title

Field Notes

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Contract Information
Data Element
†
Senior Product Contact Phone
Senior Product Contact Ext.
Senior Product Contact Alternate Phone
Senior Product Contact Alt. Ext.
Senior Product Contact Fax
†
Senior Product Contact Email
†
Senior Product Contact Address
†
Senior Product Contact City
†
Senior Product Contact State
†
Senior Product Contact Zip
Labeler Code Information

Field Notes

These fields are used to add, delete, or transfer
labeler codes

Labeler Code
Firm Name
Transfer
Transfer From (Contract ID/Information
Required If Transfer)
Reason for Request
Delete
Transfer
Transfer To (Contract ID/Information Required if
Transfer)
Reason for Request
Manufacturer Ownership Information
Data Element
†
Did the submitting Manufacturer have a
Coverage Gap Discount Program Agreement
under 42 USC § 1395w-114a in effect on
December 31, 2021? Y/N
†
Did the submitting Manufacturer have any
other corporation or business (whether or not
incorporated) in its controlled group on
December 31, 2021 that had a Coverage Gap
Discount Program Agreement under 42 USC §
1395w-114a in effect on December 31, 2021?
For the purpose of this information collection
request, “controlled group” means all
corporations or partnerships, proprietorships
and other entities treated as a single employer
under 26 U.S. Code section 52(a) or (b). Y/N
†
Manufacturer Name
†
Employer Identification Number (EIN)
*Address

Field Notes
If yes, complete the subsequent field in this
section.

If yes, complete the subsequent five (5) fields in
this section for each such additional
Manufacturer.

One or more occurrences permitted.

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Manufacturer Ownership Information
Data Element
†
Applicable Unique Identifier Assigned by CMS
(P number)
Applicable Labeler Code(s) covered under such
Coverage Gap Discount Program Agreement in
effect on December 31, 2021
†

Was the submitting Manufacturer acquired by
another Manufacturer after December 31,
2021? Y/N
*Did the acquiring Manufacturer have a
Coverage Gap Discount Program Agreement
under 42 USC § 1395w-114a in effect on
December 31, 2021? Y/N
*Manufacturer Name
* Employer Identification Number (EIN)
*Address
*Applicable Unique Identifier Assigned by CMS
(P number)
Applicable Labeler Code(s) covered under such
Coverage Gap Discount Program Agreement in
effect on December 31, 2021
†

Attestation for Manufacturer Ownership
Information (Y/N)

Agreement
Signature/Attestation
Data Element
†
Signature

Field Notes

Include all such labeler codes for products that are
produced, prepared, propagated, compounded,
converted, or processed by the Manufacturer. One
or more occurrences permitted.
If yes, complete the subsequent field in this
section.
If yes, complete the subsequent five (5) fields in
this section for the acquiring Manufacturer.

One or more occurrences permitted.

Include all such labeler codes for products that are
produced, prepared, propagated, compounded,
converted, or processed by the Manufacturer. One
or more occurrences permitted.
Must be completed by an authorized official with
electronic signature access. User reviews the
ownership information submitted for this section
and attests to its completeness and accuracy.

Field Notes
Must be completed by an authorized official with electronic signature
access. User selects “sign all documents,” checks the “Check this box
to electronically sign and date this form,” and then selects the
“Submit” button.

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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/xxxx). The time required to complete this information collection is estimated to average 6.5 hours per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete 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.

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