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 email message to vgray@bcbsm.com.

I. General contact information from the RDS application:

Street Address (required)

City (required)

ZIP Code (required)

II. Plan Information:

Plan Name (required)

Plan Year Start Date (required)

Plan Year End Date (required)

Contact's Name (required)

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)? 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

To no one (Your organization has everything it needs to report interim RDS claim data)

Directly to the following third party:

Contact's Name

Contact's Email Address

Contact's Phone Number

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

First Name

Phone Number

Last Name

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):

Title

Phone number

Fax number

Address (if different from company primary address):
Street

City

ZIP Code

Is this individual authorized to view HIPPA PHI? Yes No

VI. Account manager information (from the RDS Application):

Title

Phone number

Fax

Address (if different from company primary address):
Street

City

ZIP Code

Is this individual authorized to view HIPPA PHI? Yes No

VII. Payment requestor information (from the RDS application):

Title

Phone number

Fax

Address (if different from company primary address):
Street

City

ZIP Code

Is this individual authorized to view HIPPA PHI? Yes No

VIII. Identification of the person who completed this form:

Title

Phone number

Fax

Address (if different from company primary address):
Street

City

ZIP Code

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 Email Address