Section 204 Health Care & Pharmacy Reporting Survey for Employer Groups

Employer Groups: Florida Blue needs your help in the collection of data requirements for the Section 204 (of Title II, Division BB) of the Consolidation Appropriations Act (CAA), 2021. The data submission report is called Prescription Drug Data Collection (RxDC) and Florida Blue will report all data (with exclusion of D3-D8 drug files for Employer Groups with pharmacy carve-out) on your behalf by June 1, 2023.

In order for Florida Blue to complete this federal filing requirement on your behalf, you must complete this online survey by April 1^st, 2023. All fields are required unless otherwise indicated. You may have multiple surveys to complete if you offer PPO and HMO products to your employees.

If your plan’s renewal date is not on the first of the year, please provided all 12 months of data from January 1 to December 31, 2022.

For additional information and assistance related to the data requirements, please refer to the RxDC reporting instructions (PDF). Use Control F to search the document for keyword or phrase related to the data fields in the survey. Click here for additional data field descriptions.

Important: Remember, the deadline to submit the necessary data requirements to Florida Blue is April 1^st, 2023.

Group Information

Group Number: (must be 5 characters)

Group Name:

Person submitting the data

First Name:

Last Name:

Job Title:

Contact Email:

Contact Phone: (10 numbers only, no dashes or parentheses)

Pharmacy Benefits

Please select the option that best describes your Employer Group’s Pharmacy Benefits.

Your group funding type is Self-Insured/Level Funded

Please select your health plan Florida Blue - PPO Florida Blue - HMO (HOI)

Pharmacy Benefit Manager (PBM) Name:

PBM Employer Identification Number: (also known as Tax ID)

Department of Labor (DOL) Form 5500 Plan Number: (if applicable)

2021 Average Total Number of Employees:
(including Seasonal and Part-Time Employees)

Total premium equivalents & administrative fees (in dollars) paid by the EMPLOYER in the 2022 Calendar Year (Health & Pharmacy)

Total premium equivalents & administrative fees (in dollars) paid by the EMPLOYEE in the 2022 Calendar Year (Health & Pharmacy)

Total Administrative Services Only (ASO)/ and Third-Party Administrative (TPA) Fees (in dollars) Paid in the 2022 Calendar Year (Pharmacy Only)

Total Premium Equivalents (in dollars) Paid in the 2022 Calendar Year (Pharmacy Only)

Please select your Group Funding Type: MPP Fully Insured Self-Insured / Level Funded

Please select your health plan Florida Blue - PPO Florida Blue - HMO (HOI)

Total premium amounts (in dollars) paid by the EMPLOYER in the 2022 Calendar Year

Total premium amounts (in dollars) paid by the EMPLOYEE in the 2022 Calendar Year

Please select your health plan Florida Blue - PPO Florida Blue - HMO (HOI) Truli

Total premium amounts (in dollars) paid by the EMPLOYER in the 2022 Calendar Year

Total premium amounts (in dollars) paid by the EMPLOYEE in the 2022 Calendar Year

Please select your health plan Florida Blue - PPO Florida Blue - HMO (HOI)

Department of Labor (DOL) Form 5500 Plan Number: (if applicable)

2021 Average Total Number of Employees:
(including Seasonal and Part-Time Employees)

Total premium amounts (in dollars) paid by the EMPLOYER in the 2022 Calendar Year

Total premium amounts (in dollars) paid by the EMPLOYEE in the 2022 Calendar Year

FB RXDC 001 NF 012023

RxDC Prescription Drug Data Collection

HMO coverage is offered by Truli for Health and Florida Blue HMO, affiliates of Florida Blue. Health insurance is offered by Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.