Retiree Drug Subsidy Online Renewal Questionnaire

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

New application ID

Plan name

Plan year start date

NEED A DATE PICK COMPONENT

Plan year end date

NEED A DATE PICK COMPONENT

Frequency

Estimated number of retirees

Unique Benefit Option Identifier(s)

BCBSM

BCN

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:

Yes No

Yes No