Form CMS-10696 Drug Formulary Change Template

Center for Medicare & Medicaid Services (CMS) Qualified Health Plan Formulary Changes Reporting
Plan Year 20XX

OMB Control Number: 0938-1310
Expiration Date: XX/XX/20XX

Please complete the fields below, following the instructions in the Formulary Changes Issuer Instruction Guide.

General Information

Issuer HIOS
ID
Drug List ID

State

Drug Ingredient and Strength

Marketplace

Drug Ingredient and
Strength

Dose Form

Brand Name drug
being removed from
the formulary

Brand Name RXCUI
being removed from
the formulary

Generic drug name
being removed from
the formualry

Notes

Generic RXCUI being Was the brand name
added to the
drug moved to a higher
formulary
cost sharing tier?

Was the brand name
drug removed from the
formulary?

Date the Change
Occurred

Notes: (Please enter any
comments/notes here.)

PRA Disclosure Statement: PRA Disclosure Statement: 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 09381310. The time required to complete this information collection is estimated to average 2520 minutes, 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.
****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).