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pdfEHB-Benchmark Plan Formulary Drug List
OMB Control Number: 0938-1174
Expiration Date: XX/XX/20XX
If the State is changing its prescription drug EHB, the State must submit 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 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.
PRA DISCLOSURE: 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, expiration date XX/XX/20XX. The time required to complete this information collection is estimated to average
205 hours per response for States. 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 C4-2605, 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 Ken Buerger at [email protected].
| File Type | application/pdf |
| File Title | EHB-benchmark Plan Formulary Drug List |
| Subject | Centers for Medicare & Medicaid Services, CMS, Centers for Consumer Information & Insurance Oversight, CCIIO, State-benchmark, E |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 2024-02-12 |
| File Created | 2023-10-12 |