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Retiree Drug Subsidy Online Renewal Questionnaire

* = Required field

*Email:

Plan information (from RDS application)

*New application ID number: *Plan name: *Plan year start date: *Plan year end date: *Frequency: Monthly Annually Quarterly *Estimated number of retirees: *Unique Benefit Option Identifier(s): *Group number(s): BCBSM:  BCN 

General contact information (from RDS application)

*Has the contact information changed?  No, the contact information is the same as previous plan year.  Yes, the contact information changed. Please make the following changes:

Payment setup

*Is BCBSM named as vendor using vendor number A0013?  Yes  No *Is file submission mainframe to mainframe?  Yes  No

If you have any questions about this questionnaire, please send an email message to rdsdesignee@bcbsm.com.