Retiree Drug OLD

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







III. BCBSM Designee Information 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)

Address (if different from company primary address):

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VI. Account manager information (from the RDS Application)

Address (if different from company primary address):

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VII. Payment requestor information (from the RDS application)

Address (if different from company primary address):

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VIII. Identification of the person who completed this form:

Address (if different from company primary address):

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If No, please provide the following: