Information Collection

PBM - Annual Submission of Prescription Benefit Information

IC 243637 under ICR 202404-0938-029 · OMB 0938-1394.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10725 PBM - Annual Submission of Prescription Benefit Information	Form and Instruction
CMS-10725_Appendix_C_QHP_PBM_DPR2_Instructions_04.18.24_508.pdf	Instruction
CMS-10725 - Appendix C - QHP PBM Instructions.docx	Instruction
CMS-10725 Transparency Summary Web Form CMS-10725_Appendix_A_PBM_Transparency_Summary_Web_Form_04.18.24_508.pdf	Form and Instruction
CMS-10725 Transparency Summary Web Form CMS-10725 - Appendix A - PBM Transparency Summary Web Form.docx	Form and Instruction
CMs-10725 Transparency Detailed Template CMS-10725_Appendix_B_QHP_PBM_DPR2_Template_04.18.24_508.pdf	Form
CMs-10725 Transparency Detailed Template CMS-10725 - Appendix B - QHP PBM Template.docx	Form
CMS-10725 Transparency Attestation CMS-10725_Appendix_D_PBM_Transparency_Attestation_04.18.24_508.pdf	Form and Instruction
CMS-10725 Transparency Attestation CMS-10725 - Appendix D - PBM Transparency Attestation.docx	Form and Instruction
CMS-10725 QHP Issuer Transparency Attestation CMS-10725_Appendix_E_QHP_Issuer_Transparency_Attestation_04.18.24_508.pdf	Form and Instruction
CMS-10725 QHP Issuer Transparency Attestation CMS-10725 - Appendix E - QHP Issuer Transparency Attestation.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10725	Transparency Summary Web Form	CMS-10725 - Appendix A - PBM Transparency Summary Web Form.docx	Yes	Yes	Fillable Fileable
Form	CMs-10725	Transparency Detailed Template	CMS-10725 - Appendix B - QHP PBM Template.docx	Yes	Yes	Fillable Fileable
Instruction			CMS-10725 - Appendix C - QHP PBM Instructions.docx	Yes	No	Paper Only
Form and Instruction	CMS-10725	Transparency Attestation	CMS-10725 - Appendix D - PBM Transparency Attestation.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10725	QHP Issuer Transparency Attestation	CMS-10725 - Appendix E - QHP Issuer Transparency Attestation.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 23

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	23	-17	40
Annual IC Time Burden (Hours)	1,278	0	1,278
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.