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.

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

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

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. This information collection requires QHP issuers and Pharmacy Benefit Managers, that do not contract with a Pharmacy Benefit Manager, to administer the prescription drug benefit and report issuer and plan level prescription drug benefit information to CMS on an annual basis. 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. Pursuant to 45 CFR 156.295(a) and 184.50(a), this information collection is mandatory for PBMs to report prescription drug benefit information related to QHP issuers. HHS will use this information to understand the cost of prescription drugs and the role that PBMs play in the health care delivery process. 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 or email LeAnn Brodhead at [email protected].