CMs-10725 Transparency Detailed Template

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

Welcome to the Qualified Health Plan (QHP) Pharmacy Benefit Manager (PBM) Drug Data, Pricing, and Rebate Review (DPR2) Template.
Please note the following prior to submitting this template in the PBM Health Insurance Oversight System (HIOS) Module.
1. For detailed guidance regarding how to complete this template, as well as the PBM Module webform, please refer to the “QHP PBM DPR2 Template Instructions” document and the “HIOS PBM User Manual,” both available in
the HIOS Knowledge Center.
2. For questions related to this review, please reach out to the Marketplace Service Desk for assistance at [email protected] or at 855-CMS-1515. To ensure your ticket is routed effectively, please note the following
guidance:
2a. Please include the term “QHP PBM DPR2” in the subject line and/or body of your email or request.
2b. If you have a technical question (e.g., regarding HIOS access, role provisioning, template submission errors, or data verification failures), please specifically request support from the HIOS Technical Group.
2c. For all other questions (e.g., regarding which issuers and plans are covered by this review, how to calculate rebate values, justifications in response to corrections notices, or other substantive review issues) please indicate
that your request pertains to a policy question.
3. Please ensure that for each row, the sum of column D, “Total_Prescriptions_Dispensed_Retail_Pharmacies,” and column E, “Total_Prescriptions_Dispensed_Mail_Order_Pharmacies,” is equal to the value reported in column
C, “Total_Prescriptions_Dispensed_All.”
4. Please ensure that the values reported in column F, “Total_Rebate_Dollars,” are equal to the sum of all rebates entered on the summary webform, including PBM-retained rebates, rebates expected but not yet received, PBM
incentive payments, and all other rebates, at the NDC level.
5. Before submitting this template in HIOS, you must delete this “Instructions” tab and convert this .xlsx file into a pipe-delimited .csv file. You can complete this file conversion as outlined below:
5a. Delete this “Instructions” tab and save the template, containing only the “Data” tab, as a comma-delimited .csv file.
5b. Double-check the “NDC” column to ensure that, when converting to .csv, no leading zeros were lost (i.e., ensure that all NDC values listed are still exactly 11 digits).
5c. Close out of the new .csv file.
5d. Browse to your .csv comma-delimited file.
5e. Right-click the file, click Open with, and then click Notepad.
5f. Press Ctrl + H on your keyboard to open the Replace window in Notepad. You can also open this window by clicking Edit at the top of the window, then clicking Replace.
5g. Type a “,” into the Find what field, type a “|” into the Replace with field, and then click the Replace All button. The “|” key on your keyboard is located above the “Enter” key, if you are having trouble finding it.
5h. Close the Replace window; then save the edited file. Be sure to append the .csv file extension to the end of the file name when saving it, as Notepad may try to save the file as a .txt file.

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.

Issuer_HIOS_Plan_ID

NDC

Total_Prescriptions_Dispensed_All

Total_Prescriptions_Dispensed_Retail_Pharmacies

Total_Prescriptions_Dispensed_Mail_Order_Pharmacies

Total_Rebate_Dollars