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RxDC Survey

Contact Information

Name(Required)

Group/Tax Information

Group Product Type(Required)

Please select all product types that apply in the 2024 calendar year.

Examples:

  • If only one of the options applies, please select that group product type and report your premium amounts paid during the calendar year 2024.
  • If you transitioned from a SimpleCare Group to a 4Corners plan in the 2024 calendar year, please select both Group Product Types. You will be required to complete two sections.
  • If you renewed a SimpleCare Large Group plan or a 4Corners plan during 2024, please record the total amount of premiums paid for both plans during the 2024 calendar year.

SimpleCare Large Group Information

Please input your SimpleCare Large Group Number
MM slash DD slash YYYY
MM slash DD slash YYYY

SimpleCare Large Group Reporting Totals

Ensure accurate reporting of premiums below. Learn more in our FAQs section.

The reported amount includes all premiums paid by employees for all premium levels (EE, ES, ECH, and FAM) during the selected plan year. This includes both the actual premium paid by members and any premium equivalents paid by members for self-funded coverage. However, the reported amount does not include any premiums or premium equivalents paid by employers or other plan sponsors on behalf of members.

4Corners Level Funded Information

Please input your 4Corners Level Funded Group Number
MM slash DD slash YYYY
MM slash DD slash YYYY

4Corners Level Funded Reporting Totals

Ensure accurate reporting of premiums below. Learn more in our FAQs section.

The reported amount includes all premiums paid by employees for all premium levels (EE, ES, ECH, and FAM) during the selected plan year. This includes both the actual premium paid by members and any premium equivalents paid by members for self-funded coverage. However, the reported amount does not include any premiums or premium equivalents paid by employers or other plan sponsors on behalf of members.

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