Prescription Drug Data Collection (RxDC) Form

EmblemHealth Prescription Drug Data Collection (RxDC) Plan Sponsor Data Collection Report Coverage Year 2024

Please complete and submit this form by May 9, 2025 for any EmblemHealth medical plan purchased for Coverage Year 2024 (full year or any portion of the year). Please reach out to your Senior Account Executive with any questions about completing this form.

Group Name

Group Address

EmblemHealth Group Number* as indicated on your invoice

*Seven-digit group number (e.g. 11XXXXX)

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

RxDC Plan Sponsor Data Collection Form

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Prescription Drug Data Collection (RxDC) Form

EmblemHealth Prescription Drug Data Collection (RxDC) Plan Sponsor Data Collection Report Coverage Year 2024

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