Form CMS-10725 Transparency Summary Web Form

OMB Control Number: 0938-1394
Expiration Date: XX/XX/20XX
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.
Plan 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

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 0938-1394. The
information collection included in this package reflects the time and effort for submitters to provide prescription drug benefit
information to CMS using the Health Information Oversight System (HIOS) module. The time required to complete this
information collection is estimated to average 122 hours per response, including the time to review instructions, search existing
data resources, gather the data needed, and to review and complete the information collection. This information collection,
pursuant to 45 CFR 156.295(a) and 184.50(a), requires PBMs to report prescription drug benefit information related to QHP
issuers. All information collected will be kept private in accordance with regulations at 45 C.F.R. 155.260, Privacy and Security of
Personally Identifiable Information. 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, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850,
Attention: Information Collections Clearance Officer.