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RxDC Plan Sponsor Data Collection for 6/1/23 Reports

Fields with an * are required.

Note: Plan Sponsors must complete and submit this form separately for each product that Aetna underwrites or administers for the reference year.

Reach out to your account representative for questions on completing this form.

Enter 9 digits (e.g., 123456789)

TOTAL Premium Paid by:

self-insured, fully insured, split-funded
Refer to your contract to locate the Legal Entity where products are offered and/or underwritten

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

Health benefits and health insurance plans contain exclusions and limitations.

Also of interest: