Form CMS-10722 Annual State Report on CMS VBP Supplemental Rebate Agree

PRA Disclosure Statement The purpose of the PRA package is to collect specific information from states regarding CMS-authorized supplemental
rebate agreements that include value-based payment arrangements (VBP). The reporting is mandatory as required by 42 CFR 447.518(d). Under
the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
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 0938-1385 (Expires: TBD). The time required to complete this
information collection is estimated to average 6 hours per response, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. 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, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

Annual State Report on CMS VBP Supplemental Rebate Agreements

Calendar Year

Product FDA List Name

2023 Drug A Name
2024 Drug B Name
2023 Drug A Name
2024 Drug B Name

NDC for drugs covered by VBP

NDC - 1, NDC - 2, NDC - 3, NDC 4
NDC - 1, NDC - 2
NDC - 1, NDC - 2, NDC - 3, NDC 4
NDC - 1, NDC - 2

Number of Prescriptions
(number of beneficiaries)

Cost to State to Administer VBP (need
standard computation)

250 $

Total Revenue received by
supplemental rebate under VBP
by end of calendar year
75,000 $
225,000

Total Savings generated by supplemental
rebate under VBP
$

150,000

100 $
400 $

50,000 $
75,000 $

350,000
225,000

$
$

300,000
150,000

50 $

50,000 $

350,000

$

300,000

Notes

Data Element Definitions

Calendar Year

Enter the calendar year in the following format: i.e. "2023", "2024"

Product FDA List Name

For each VBP arrangement which the State received manufacturer rebates in the prior CY.

NDC

NDC 9s used in arrangement (at dosage form and strength level). Example: 00001-1234, 1244, 1254,

# of Prescriptions (number of
beneficiaries)

The # of prescriptions (number of beneficiaries) field should reflect the # of Medicaid beneficiaries receiving the prescribed treatment
whether single or multiple doses under the state's VBP for the NDC 9s listed. State should reflect # of beneficiaries receiving treatment over
the year because the outcome and the rebate the state receives is based on a single beneficiary’s outcome and not the outcome of a single
prescription.
Cost to the State to Administer VBP
Calculated as the estimated administrative costs to the state to enter into and administer each VBP arrangement. Examples of administrative
(Estimated to the nearest dollar. States costs states may incur: The costs applicable to negotiating the contract, the applicable cost of collecting data, the applicable cost of a
may approximate the amount of
contract with a fiscal agent to develop, invoice and collect rebates, applicable costs to entities collecting and verification of patient or
administrative costs for a single
population data, state cost of filling out this survey. For reporting purposes states can consolidate its administrative, and if applicable, clinical
administrative contract used for multiple costs associated with the VBP arrangement.
arrangements.)
States do not need to determine the precise cost of administering each contract and may estimate the percentage of time its state
employees dedicated to VBP arrangements in comparison to the rest of their duties for this data element. Approximating % of FTE salary
dedicated to VBP contracts/# VBP arrangements the state employee oversees would be appropriate. For example - employee’s annual salary
is $60,000 and spends 10% of their time on VBP arrangement negotiation and administration. The state has 6 VBP contracts the employee
sees. Therefore, for each VBP contract the state has estimated a $1000 cost associated with operating the contract.
*We understand that there may be start-up costs only reflected in the first year.
Total Revenue received by supplemental This should field should only include rebate revenue generated by the VBP arrangement.
rebate under VBP
by end of calendar year
Total Savings generated by the
supplemental rebate due to VBP
(Estimated to the nearest dollar)

Annual report due

This field is populated via formula.

The period for the VBP reporting will be on CY. Therefore, the first reporting period will include VBP arrangements in effect during CY 2022
(1/1/2022 through 12/31/22). The submission of reports for the CY 22 will take place 60 days after the end of CY or March 1, 2023. If the
state needs to update the report with additional (lagged) information after the 60 day cut off, the state may resubmit the report with the
updated information.