CMS-10725 Transparency Attestation

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

Pharmacy Benefit Manager Transparency for Qualified Health Plans Attestation
Appendix D – Attestation
Section 1150A of the Social Security Act requires an entity that provides pharmacy benefit
management services on behalf of a health benefit plan that manages prescription drug coverage
under a contract with a Qualified Health Plan (QHP) offered through an Exchange report the
certain prescription drug and pharmacy benefit management financial data to the Centers for
Medicare and Medicaid Services (CMS). The official listed below, signing on behalf of
(“the PBM”), makes the following attestation
concerning the accompanying data reporting:
I attest that I am aware of what is included in the PBM’s data reporting. I attest on behalf of the
PBM (based on best knowledge, information, and belief), that the data submitted to CMS are
accurate, complete, and truthful.

Name of PBM

Printed Name of PBM Official Authorized to Sign

Date

Signature of PBM Official Authorized to Sign

Title/Position

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.