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Prescription Drug Data Collection (RxDC) Form

ConnectiCare Prescription Drug Data Collection (RxDC) Plan Sponsor Data Collection Report Coverage Year 2023

Please complete and submit this form by May 3, 2024 for any ConnectiCare medical plan purchased for Coverage Year 2023 (full year or any portion of the year). Please reach out to your Account Manager with any questions about completing this form.

Group Name

Group Address

ConnectiCare Group Number* as indicated on your invoice

*Seven-digit group number (e.g. 11XXXXX).
For ALL small groups and Fixed Funding groups administered by CBIA please use the number on your invoice (e.g. 90XXXXX).

ConnectiCare already has your premium information in our billing system. Please provide:

Average % of medical premium paid by employer:

Average % of medical premium paid by employee:

The two percentages of medical premium paid by employer and medical premium paid by employee must equal 100%.

Submitter Name

Submitter Email Address

employer

Access the ConnectiCare Portal

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary,or other plan documents for specific information about your benefits coverage.