CMS-10448 Benchmark Plans Prescription Template

EHB-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.

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. The
information collection included in this package reflects the time and effort for states to select a new EHB-benchmark plan.
The time required to complete this information collection is estimated to average less than 205 hours per response, including
the time to review instructions, search existing data resources, gather the data needed, to review and complete the
information collection. This information collection, pursuant to 45 C.F.R. 156.111, requires states who wish to modify their
benchmark plans to respond to this ICR. All information collected will be kept private in accordance with regulations at 45
C.F.R. 155.260, Privacy and Security of Personally Identifiable Information. 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, Mail Stop
c4-26-05, Baltimore, Maryland 21244-1850, Attention: Information Collections Clearance Officer, or email Ken Buerger at
[email protected].