Aetna Prescription Drug Data Collection Reporting Submission

Plan Sponsor

Plan Sponsor Unique ID

Also known as Account ID for Small Group

Submitter First Name

Submitter Last Name

Submitter Email

Legal Entity Name

Funding Arrangement

Total Premium paid by Employer

Currency only: no special characters beyond "." (ex: % or $)

Total Premium paid by Members

Currency only: no special characters beyond "." (ex: % or $)

Plan Sponsor SF ID

TRUE