2026 RxDC Request for Information

RxDC Request for Information - Self-Funded
In compliance with the CAA Prescription Drug Data Collection (RxDC) Reporting, CDPHN is requesting completion of this data questionnaire by April 15, 2026. All data submission should be based on the reference year 2025 and plan(s) administered by CDPHN. We will use this data for our submission to CMS due on June 1, 2026.

Please note: Only one submission will be accepted per CDPHP Group ID.

RxDC Request for Information - Self-Funded
Name*

First NameLast Name
Email*

Confirmation EmailYou will receive a confirmation and reminder emails at this address you provide.
CDPHP Group Name*
Found on upper left corner of CDPHP monthly invoice.
CDPHP Group ID*
8 digits only - found on upper right corner of CDPHP monthly invoice
EIN*
Federal Tax ID Number. 9 digits only. No special characters or slashes.
Human Resource RepresentativeBenefit CoordinatorBrokerOther

RxDC Request for Information - Self-Funded
Average Monthly Employer Premium (Percentage)*
What is the average percent of monthly premium paid by employer?
Average Monthly Member Premium (Percentage)*
Average percent of monthly premium paid by member. Calculated from Average Monthly Employer Premium
Average Monthly Employer Premium + Average Monthly Member Premium

must equal 100%.
Life Years for 2025
Round to the 5th decimal place, numeric values and decimals only
Premium Equivalents for 2025
Round to the 5th decimal place, numeric values and decimals only
ASO/TPA Fees Paid for 2025
Report the ASO and other fees paid to the TPA. This amount should also be included in Premium Equivalents. Round to the 5th decimal place, numeric values and decimals only
Stop Loss Premium Paid for 2025
Report the stop loss premium paid to the insurer. This amount should also be included in Premium Equivalents. This amount should also be included in Premium Equivalents. Round to the 5th decimal place, numeric values and decimals only
Should be Empty:

RxDC Request for Information - Self-Funded