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

By signing this document the signatory is attesting that the information contained within is true to the best of their knowledge. If false information is provided or information is hidden from the Centers for Medicare and Medicaid Services, the signatory may be fined up to $10,000 or imprisoned up to five years, or both (18 U.S.C. 1001). Defer to the agency on the appropriateness of other citations (e.g., 42 U.S.C. 1396r–8(b)(3)(C)).

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].