Information Collection

EHB Benchmark Plan Formulary Drug

IC 241291 under ICR 202408-0938-009 · OMB 0938-1174.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10448 EHB Benchmark Plan Formulary Drug	Form and Instruction
Form CMS-10448 EHB Benchmark Rx Plan EHB Benchmark Plan Formulary Drug	Form and Instruction
CMS-10448 EHB Benchmark Rx Plan CMS-10448_Appendix_D_EHB_Benchmark_Plan_Rx_508.pdf	Form and Instruction
CMS-10448 EHB Benchmark Rx Plan CMS-10448_Appendix_D_EHB_Benchmark_Plan_Rx_508.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.111(e)(3)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10448				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	5	-36	41
Annual IC Time Burden (Hours)	60	41	19
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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