Retiree Drug Subsidy Questionnaire

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Home > Agent Home > Medicare Part D Prescription Drug Coverage > Retiree Drug Subsidy Questionnaire

Return to Medicare Retiree Drug Subsidy Process

Please complete this form, using the information from your organization's application to CMS for the Retiree Drug Subsidy Option. If your organization received approval for more than one drug subsidy application, complete a separate template for each approved application.

* = Required field

I. General contact information from the RDS application: *Company name: *Street Address: *City: *State: *ZIP:

II. Plan Information *RDS application ID number: *Plan Name: *Plan Year Start Date: *Plan Year End Date: Does this RDS Application include Medicare-covered individuals with (check all that apply): BCN BCBSM BCBSM Master Medical Other *How frequently did your organization indicate that it would be submitting interim RDS claim payment data to CMS(select one)? Annually Interim Annually Quarterly Monthly To whom will you want BCBSM and/or BCN to provide Drug Subsidy interim claim payment data? Please select all that are applicable to your group. To CMS on your behalf Directly to you Directly to the following third party

Contact's Name: Contact's Phone Number: Contact's e-mail address:

To no one. (Your organization has everything it needs to report interim RDS claim data) Which CMS defined method are you planning to use for RDS retiree list submissions? Hypertext transfer protocol secure (HTTPS) to RDS Center Plan Sponsor Mainframe to RDS Center Mainframe Voluntary Data Sharing Agreement (VDSA) Who should BCBSM/BCN work with at your organization in regard to any technology related issues associated with the Retiree Drug Subsidy Option? *First Name: *Last Name: *Phone:

III. BCBSM Designee Information *Did you elect to have BCBSM/BCN be a Designee for your RDS application for the role of 'View/Send/Receive Retiree Data'? Yes No

IV. Benefit Option(s) Included in the RDS Application

For this Application ID Number, please list all the benefit option names and their BCBSM or BCN group number. If you have any subscribers that have prescription drug coverage under a Master Medical plan, those subscribers are ineligible for this subsidy. Please list only those groups that are not part of a Master Medical plan.

Option name

Group number

Membership count

V. Authorized Representative Information (from the RDS Application) *Authorized Representative's Full Name: Title: *Email: *Phone number: Fax:

Address (if different from company primary address):

Street: City: State: ZIP:

*Is this individual authorized to view HIPPA PHI?

Yes No

VI. Account manager information (from the RDS Application) Account manager's Full Name: Title: Email: Phone number: Fax:

Address (if different from company primary address):

Street: City: State: ZIP: Is this individual authorized to view HIPPA PHI? Yes No

VII. Payment requestor information (from the RDS application) Account manager's Full Name: Title: Email: Phone number: Fax:

Address (if different from company primary address):

Street: City: State: ZIP:

Is this individual authorized to view HIPPA PHI?

Yes No

VIII. Identification of the person who completed this form: *Account manager's Full Name: Title: *Email: *Phone number: Fax:

Address (if different from company primary address):

Street: City: State: ZIP:

*Is this the person to contact with any questions about the information provided in this form?

Yes No

If No, please provide the following:

Contact's Name: Contact's Phone Number: Contact's e-mail address:

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

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