CMS-10448 Benchmark Plans Prescription Template

EHB-benchmark Plan Formulary Drug List
If the State is selecting the option at 45 CFR 156.111(a)(3) to change its EHB-benchmark Plan, the State must submit
to CMS a formulary drug list using this template when the State submits its EHB-benchmark plan.
Instructions: The State must submit the template provided by HHS for the formulary drug list as a list of RxNorm
Concept Unique Identifiers (RXCUIs). A complete list of RxNorm Concept Unique Identifiers (RXCUIs) for all
prescription drugs that are covered by the new State's EHB-benchmark Plan, regardless of tier placement and
medical utilization management. If the State is creating its own benchmark plan, the States should use the most
recent RxNorm information.
RXCUIs group chemically identical drugs into code numbers by ingredient, strength, dose form and brand name. For
example:
• RXCUI 860975 = Metformin 500 MG Oral Tablet
• RXCUI 860977 = Metformin 500 MG Oral Tablet [Glucophage]
• RXCUI 860981 = Metformin 750 MG Oral Tablet
Enter only RXCUIs numerical values below.
RxCUI