Retiree Drug Subsidy Questionnaire

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.

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

I. General contact information from the RDS application:
II. Plan Information

Does this RDS Application include Medicare-covered individuals with (check all that apply):

  • Blue Care Network
  • Blue Cross Blue Shield of Michigan
  • Blue Cross Blue Shield of Michigan Master Medical
  • Other

How frequently did your organization indicate that it would be submitting interim RDS claim payment data to CMS (select one)?

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
  • To no one (Your organization has everything it needs to report interim RDS claim data)
  • Directly to to the following third party:

Which CMS defined method are you planning to use for RDS retiree list submissions?

III. BCBSM Designee Information
IV. Benefit Option(s) Included in the RDS Application

Option name

Group number

Membership count

V. Authorized Representative Information (from the RDS Application)

Is this individual authorized to view HIPPA PHI?

VI. Account manager information (from the RDS Application)

Is this individual authorized to view HIPPA PHI?

VII. Payment requestor information (from the RDS application)

Is this individual authorized to view HIPPA PHI?

VIII. Identification of the person who completed this form:

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

If no, please provide the following: