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PBM - Annual Submission of Prescription Benefit Information
Pharmacy Benefit Manager Transparency (CMS-10725)
OMB: 0938-1394
IC ID: 243637
OMB.report
HHS/CMS
OMB 0938-1394
ICR 202404-0938-029
IC 243637
( )
Documents and Forms
Document Name
Document Type
Form CMS-10725
PBM - Annual Submission of Prescription Benefit Information
Form and 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 Detailed Template
CMS-10725_Appendix_B_QHP_PBM_DPR2_Template_04.18.24_508.pdf
Form
CMS-10725_Appendix_C_QHP_PBM_DPR2_Instructions_04.18.24_508.pdf
Instruction
CMS-10725 Transparency Attestation
CMS-10725_Appendix_D_PBM_Transparency_Attestation_04.18.24_508.pdf
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
Information Collection (IC) Details
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