EHB Benchmark Plan Formulary Drug

Essential Health Benefits Benchmark Plans (CMS-10448)

Documents and Forms

Document Name Document Type
Form CMS-10448 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

Information Collection (IC) Details

IC Title:	EHB Benchmark Plan Formulary Drug	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10448	EHB Benchmark Rx Plan	CMS-10448_Appendix_D_EHB_Benchmark_Plan_Rx_508.pdf		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 %

	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

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.