CMS-10448 Benchmark Plans Prescription Template

EHB-benchmark Plan Formulary Drug List

OMB Control Number: 0938-1174
Expiration Date: 06/01/2021

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. Please note that, pursuant to 45 CFR 156.122, if the EHB-benchmark plan does not include any
coverage in a USP category and/or class, then the count is zero. EHB plans must cover at least one drug in that USP category and/or class.
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 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

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 0938-1174 (Expires 06/01/2021). The time required to complete this
information collection is estimated to average 47 hours or 2,820 minutes per response for States. For Form 1, the estimate is 4 hours. For Form 2,
the estimate is 19 hours. For Form 3, the estimate is 12 hours. For Form 4, the estimate is 12 hours. 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 Valisha Jackson at [email protected].