Skip to content
Rx DC Disclosure
RxDC-Prescription Drug Data Collection
Company Name
Federal Tax ID
EmployerID
(Required)
this is the id that is used for web portals and PKId
Carrier Due Date
MM slash DD slash YYYY
Email Subject Line From Carrier
Survey Link
Is your group Self-Funded (ASO), Fully Insured (FI), Both or Level Funded?
Fully Insured (FI)
Self Funded (ASO)
Both
Is this an Administrative Services Only (ASO) group?
Yes
No
Do you file a form 5500 report with the IRS?
Yes
No
Group Form 5500 Plan Number
ERISA Plan Name
“Group health plan name” is the employee plan name under ERISA (Employee Retirement Income Security Act) for which an employer provides medical care to employees or their dependents directly or through insurance, reimbursement, or otherwise. This will also be the name associated with the Form 5500 Filing
Group Form 5500 Plan Number
Group Administrator
First
Last
Group Administrator Email
Medical Group Number
Enter the zip code for the mailing address for this group number.
Medical Carrier
Anthem Blue Cross
United Healthcare
Blue Shield of CA
California Choice
Kaiser Permanente
Health Net
AETNA
NONE
BlueCross BlueShield of Texas
Average Monthly Premium Paid by Employee/Member
Average Monthly Premium Paid by Employer/Group
Average Monthly Percentage of Premium covered by Employee/Member
Average Monthly Percentage of Premium covered by Employer/Group
Do you offer another health plan insurer or vendor to your employees? (P2)
Yes
No
What is name and EIN of health plan insurer
Health Plan Insurer
Health Plan Insurer EIN
Add
Remove
Do you offer other pharmacy benefit plans to your employees? (P2)
Yes
No
Do you offer other/carveout/external wellness benefits where claims are paid by the external TPA? (P2)
Yes
No
Do you offer other/carveout/external behavioral health benefits? (P2)
Yes
No
RxDC Process Date
MM slash DD slash YYYY
Learn how we helped 100 top brands gain success
Full Name
Phone
Email
Send
