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

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