CMS-10170 Retiree Drug Subsidy Payment

Retiree Drug Subsidy Payment Request Instructions (CMS-10170)

CMS10170RDSApplication (002)

Retiree Drug Subsidy (RDS) Payment Request and Instructions (public, private and union sponsors)

OMB: 0938-0977

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0977 can be found here:

2024-09-23 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

An asterisk (*) identifies a required field.

OMB Approval # 0

PART I.
A. Plan Sponsor Account Registration
1) *Organization’s Name (Must correspond with the information associated with the Federal Employer Tax
Identification Number (EIN):
2) *Type of Organization:
Government
Union
Religious
Commercial
Non-profit
3) *Organization’s Employer Identification Number (EIN):
4) *Organization’s Telephone Number:
5) Organization’s FAX Number

ext.

6) *Organization’s Address (must be the address associated with the EIN provided above):
* Street Line 1
Street Line 2
*City

*State/US Territory

*Zip Code

7) Organization’s Website: http://
B. Authorized Representative Invitation
1)*E-mail Address:
3)*First Name

2)*Re-enter E-mail Address
4)Middle Initial (optional):

5)*Last Name

C. Authorized Representative Information
1) *Check box to agree that the Account Manager listed is associated with this plan sponsor
2) *Read and accept the User Agreement and Privacy Policy (located in Part I Section G of this document)
3) *First Name:
4) *Job Title:

Middle Initial:

*Last Name:

5) *Date of Birth(Month/Day/Year):

6) *Social Security Number:

7) *E-mail Address:
8 *Telephone Number:

ext

9) FAX Number:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-0977. The time required to complete this information collection
is estimated to average 64 hours per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.
CMS Form # 10170

An asterisk (*) identifies a required field.

OMB Approval # 0

10) * Address:
* Street Line 1
Street Line 2
*City

*State/US Territory

*Zip Code

11) *Login
*Login ID:
*Password:
*Re-enter password:
*Security Question 1
*Answer 1
*Security Question 2
*Answer 2
D. Account Manager Information
1) *Read and accept the User Agreement and Privacy Policy (located in Part I Section G of this document)
2) *First Name:

Middle Initial:

*Last Name:

3) *Job Title:
4) *Date of Birth (Month/Day/Year):

5) *Social Security Number:

6) *E-mail Address:
7) *Telephone Number:

8) FAX Number :

9) *Address:
*Street Line 1
Street Line 2
*City

*State/US Territory

*Zip Code

10) *Login
*Login ID:
*Password:
*Re-enter password:
*Security Question 1
*Answer 1

An asterisk (*) identifies a required field.

OMB Approval # 0

*Security Question 2
*Answer 2

E. Designee Invitation
1)*E-mail Address:

2)*Re-enter E-mail Address:

3)*First Name:

4) Middle Initial (optional):

6)*Pass Phrase:

5)*Last Name:

7)*Re-Enter Pass Phrase:

8)* Please choose the actions that the designee can perform for this application
F. Designee Information
1) *Enter the Pass-phrase:
2)*Read and accept the User Agreement and Privacy Policy (located in Part I Section G of this document)
3) *First Name:

Middle Initial:

*Last Name:

5) *Date of Birth (Month/Day/Year):

4) *Job Title:

6) Social Security Number:

7) E-mail Address:
8) Telephone Number:

ext.

9) FAX Number :

10) *Address:
*Street Line 1
Street Line 2
*City

*State/US Territory

*Zip Code

11) *Login
*Login ID:
*Password:
*Re-enter password:
*Security Question 1
*Answer 1
*Security Question 2
*Answer 2

An asterisk (*) identifies a required field.

G. User Agreement and Privacy Policy
THE FOLLOWING DESCRIBES THE TERMS AND CONDITIONS ON WHICH THE CENTERS FOR MEDICARE &
MEDICAID SERVICES (CMS) OFFERS YOU ACCESS TO CMS’ RDS CENTER’S SECURE WEB SITE.
You must read and accept the terms and conditions contained in this User Agreement expressly set out below and
incorporated by reference before you may access the RDS Secure Web Site.
CMS’ RDS Center may amend this User Agreement at any time. Except as stated below, all amended terms shall
automatically be effective 30 days after they are initially posted on the Site. This User Agreement is effective
immediately.
1. Purpose of the RDS Secure Web Site
CMS has recently published the final regulations for Title I and Title II of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (MMA). Title I and its implementing regulations at 42 C.F.R §423 Subpart R contain the
provisions governing the Retiree Drug Subsidy (RDS) option designed to assist employers, unions, and other Plan
Sponsors that continue to provide high quality prescription drug coverage to their retirees.
The RDS Secure Web Site provides Plan Sponsors with the resources required to become a participant in the RDS
Program, including specific instructions and assistance during the application period and afterward.
2. Privacy Policy
The U.S. Department of Health and Human Services (HHS) of which the RDS Secure Web Site is a part, has a clear
privacy policy. When you access the RDS Secure Web Site, we collect the minimum amount of information about you
necessary to process your application for the RDS Program and to manage your account.
Information Automatically Collected and Stored
When you browse through any web site, certain personal information about you can be collected. We automatically
collect and temporarily store the following information about your visit:
•
•
•
•

the name of the domain you use to access the Internet (for example, aol.com, if you are using an America
Online account, or stanford.edu, if you are connecting from Stanford University's domain)
the date and time of your visit
the pages you visited
the address of the web site you came from when you came to visit

This information is used for statistical purposes only and to help us make this site more useful to visitors. Unless it is
specifically stated otherwise, no additional information will be collected about you.
Information Collected to Process Applications and Manage Accounts Through the RDS Secure Web Site
When you apply for the RDS Program through the RDS Secure Web Site, we will collect personal information
necessary to validate participants, and to process and manage the application. The authority to collect this information
is granted by §1860D-22 of the Social Security Act and CMS’ RDS implementing regulations at 42 C.F.R. §423

OMB Approval # 0

An asterisk (*) identifies a required field.

Subpart R, as well as the Debt Collection Improvement Act of 1996 at 31 U.S.C. §7701(c) and the Federal Privacy Act
at 5 U.S.C. §552a. This may include your name, address, telephone and fax numbers, e-mail address, social security
number, drivers license photocopy, Federal Employer Identification Number (FEIN), banking information or other
payment information. Provision of this information is mandatory for participation in the RDS Program. CMS’ RDS
Center may also collect a password and password hint for each participant accessing the RDS Secure Web Site. We
use this information to verify participants' identities in order to prevent unauthorized access to secure RDS Secure Web
Site accounts.
CMS’ RDS Center staff has role-based access to this information, and use only the information minimally necessary to
accomplish their jobs.
The personal information you provide is encrypted and sent to us using a secure method, in order to assure that your
personal information is securely and safely transmitted. However, no one can give an absolute assurance that
information intended to be maintained as private, whether transmitted via the Internet or otherwise, cannot be
accessed inappropriately or unlawfully by third parties. We have taken and will continue to take reasonable steps to
ensure the secure and safe transmission of your personal information.
Personally Provided Information
If you are not involved with the submission or management of an RDS Program application on the RDS Secure Web
Site, you do not have to give us personal information. If you choose to provide us with additional information about
yourself through e-mail, forms, surveys, etc., we will maintain the information as long as needed to respond to your
question or to fulfill the stated purpose of the communication.
Disclosure
HHS and CMS do not disclose, give, sell or transfer any personal information about its visitors, unless required for law
enforcement or statute.
Intrusion Detection
The RDS Web Sites are maintained by the U.S. Government. It is protected by various provisions of Title 18, U.S.
Code. Violations of Title 18 are subject to criminal prosecution in Federal court.
For site security purposes and to ensure that this service remains available to all participants, we employ software
programs to monitor traffic to identify unauthorized attempts to upload or change information, or otherwise cause
damage. In the event of authorized law enforcement investigations, and pursuant to any required legal process,
information from these sources may be used to help identify an individual.
3. Systems of Records
Information originally collected in traditional paper systems can be submitted electronically, i.e., electronic commerce
transactions and information updates about eligibility benefits. Electronically submitted information is maintained and
destroyed pursuant to the Federal Records Act and in some cases may be subject to the Privacy Act. If information
that you submit is to be used in a Privacy Act system of records, there will be a Privacy Act Notice provided.

OMB Approval # 0

An asterisk (*) identifies a required field.

4. Links
References from RDS web sites to any non-governmental entity, product, service or information do not imply
endorsement or recommendation by CMS, HHS or any other HHS agency or employees.
We are not responsible for the contents of any "off-site" web pages referenced from this server. We do not endorse
ANY specific products or services provided by public or private organizations. In addition, we do not necessarily
endorse the views expressed by such sites, nor do we warrant the validity of any site's information or its fitness for any
particular purpose.
5. Pop-up Advertisements
When visiting RDS web sites, your web browser may produce pop-up advertisements. These advertisements were
most likely produced by other web sites you visited or by third party software installed on your computer. CMS does not
endorse or recommend products or services for which you may view a pop-up advertisement on your computer screen
while visiting our site.
6. Outdated Information
Many HHS/CMS documents are time sensitive. Department policies change over time. Information in older documents
may be outdated. You also may wish to review our Privacy Policy in section 2.
7. Accessibility
This page provides information for those visitors who use assistive or other devices to access the content on the RDS
web sites. Please see Contact Us at if you have general questions and comments or have difficulty finding something
on this site.
Synopsis of Section 508 Accessibility Requirements
The Centers for Medicare & Medicaid Services (CMS’) Retiree Drug Subsidy (RDS) Program is committed to making
all RDS Web Sites accessible to the widest possible audience, including individuals with disabilities. In keeping with its
mission, the RDS Center complies with the regulations of Section 508 of the Rehabilitation Act and the Department of
Health & Human Services (HHS) Section 508 Implementation Policy. The information contained within the RDS Web
Sites are intended to be accessible through screen readers and other accessibility tools. If alternative means of access
to any information contained on RDS Web Sites are needed, or interpreting any information proves difficult, please
contact the RDS Help Line. Call (877) RDS-HELP or (877) 737-4357. TTY for hearing impaired: (877) RDS-TTY0, or
(877) 737-8890. E-mail rds@cms.hhs.gov. In an e-mail, please indicate the nature of the accessibility problem
including the accessibility tool and web browser used, the web page address that is causing difficulty, contact name, email address, and phone number. Please do not include any Protected Health Information (PHI), as defined in the
Health Insurance Portability and Accountability Act (HIPAA), in the e-mail.
8. Freedom of Information Act (FOIA)
The RDS Web Sites are a service of the U.S. Department of Health and Human Services. Any Freedom of Information
Act (FOIA) requests concerning the RDS Web Sites should be submitted in accordance with the Department's FOIA
guidelines. Information on making FOIA requests is available at the Freedom of Information Group page. You also may

OMB Approval # 0

An asterisk (*) identifies a required field.

wish to review our Privacy Policy in Section 2.

H. Multi-Factor Authentication (MFA)
1. Text-Enabled Device (optional)
Text-enabled Device Number :
Verification Code :
2. Scan QR Code or manually enter the Secret Key from Google Authenticator _____________
3. Google Authenticator Token ________________________

OMB Approval # 0

An asterisk (*) identifies a required field.

OMB Approval # 0

PART II.
A. Plan Information
1) *Plan Name:

2) *Plan Year - Start Date:

End Date:

B. Benefit Option(s) Provided Under This Plan
1a) *Benefit Option Name:
1b) *Unique Benefit Option Identifier:
1c) *Benefit Option Type: Self-Funded
Administrator Company Name:

Fully-Insured

1d) Benefit

C. Actuary Invitation
1)*First Name:
2)Middle Initial:
3)*Last Name:
4)* Actuary AAA Membership Number:
5)*E-mail Address:
6)*Re-enter E-mail Address:
D. Actuary Information
1) * Actuary AAA Membership Number:
2) *Read and accept the User Agreement and Privacy Policy (located in Part I Section G of this document)

3)*First Name:

Middle Initial (optional):

4) *Social Security Number:
6)Job Title:

*Last Name:

5) *Date of Birth (Month/Day/Year):
7)Actuary’s Company Name:

8) *E-mail Address:
9) *Phone Number:

10) FAX Number :

11) *Address:
*Street 1
Street 2
*City
12) *Login

*State/US Territory

*Zip Code

*Login ID:
*Password:

An asterisk (*) identifies a required field.

*Re-enter password:
*Security Question 1
*Answer 1
*Security Question 2
*Answer 2

OMB Approval # 0

An asterisk (*) identifies a required field.

PART III.
A. Benefit Option Combination Question
1)*In calculating the actuarial Net Value of the benefit option(s) listed in this Plan Sponsor Application (Please select one
of the following:
(i) Each Benefit Option individually meets the Net Value test as set forth at 42 C.F.R. §423.884(d)
(ii) Two or more Benefit Options have been combined in order to meet the Net Value test as set forth at 42 C.F.R.
423.§884(d), and each option not so combined individually meets the Net Value test as set forth in 42 C.F.R. §884
Note: Based on the answer to the above question the actuary will be presented with the corresponding Actuarial
Attestation agreement. (B (i) or B (ii)).
B (i). *Actuarial Attestation for the Gross and Net Value Tests if no Benefit options are combined
I hereby attest to the following:
I am a qualified actuary and a member of the American Academy of Actuaries. I am familiar with the requirements for,
and am qualified to prepare, a Retiree Drug Subsidy (RDS) Actuarial Attestation.
The actuarial Gross Value of each of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the
actuarial Gross Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D
eligible individuals who are participants and beneficiaries of the Plan Sponsor’s plan for the subject plan year.
I have determined that each of the Benefit Option(s) listed in this Plan Sponsor Application meet the Gross Value Test
requirements of 42 C.F.R. §423 884(d), including the relevant actuarial guidelines issued by CMS, and the data and
assumptions used in the development of this attestation are reasonable and are based on generally accepted actuarial
principles, including the appropriate actuarial standards of practice.
Each Benefit Option individually meets the Net Value test as set forth at 42 C.F.R. §423.884(d).
The actuarial Net Value of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the actuarial
Net Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D eligible
individuals who are participants and beneficiaries of the Plan Sponsor’s Plan for the subject plan year.
The Net Value of the Plan Sponsor’s prescription drug coverage was determined using a methodology consistent with
the requirements set forth at 42 C.F.R. §423.884(d)(5) and all relevant actuarial guidelines issued by CMS, and the data
and assumptions used in the development of this attestation are reasonable and are based on generally accepted
actuarial principles, including the appropriate actuarial standards of practice.
I understand and acknowledge that the information being provided in this attestation is being used to obtain Federal
funds.
I agree to maintain and make available reports, working documents and other records as required under 42 C.F.R.
423.§888(d). This includes information about data and/or assumptions I may have relied upon.
I certify that this attestation is true and accurate to the best of my knowledge and belief.
Electronic Signature

OMB Approval # 0

An asterisk (*) identifies a required field.

B(ii). * Actuarial Attestation for the Gross and Net Value Tests if benefit options are combined
I hereby attest to the following:
I am a qualified actuary and a member of the American Academy of Actuaries. I am familiar with the requirements for,
and am qualified to prepare, a Retiree Drug Subsidy (RDS) actuarial attestation.
The actuarial Gross Value of each of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the
actuarial Gross Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D
eligible individuals who are participants and beneficiaries of the Plan Sponsor’s plan for the subject plan year.
I have determined that each of the Benefit Option(s) listed in this Plan Sponsor Application meet the Gross Value Test
requirements of 42 C.F.R. §423 884(d), including the relevant actuarial guidelines issued by CMS, and the data and
assumptions used in the development of this attestation are reasonable and are based on generally accepted actuarial
principles, including the appropriate actuarial standards of practice.
Two or more Benefit Options have been combined in order to meet the Net Value test as set forth at 42 C.F.R.
423.§884(d), and each option not so combined individually meets the Net Value test as set forth in 42 C.F.R. §884(d)
The actuarial Net Value of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the actuarial
Net Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D eligible
individuals who are participants and beneficiaries of the Plan Sponsor’s Plan for the subject plan year.
The Net Value of the Plan Sponsor’s prescription drug coverage was determined using a methodology consistent with
the requirements set forth at 42 C.F.R. §423.884(d)(5) and all relevant actuarial guidelines issued by CMS, and the data
and assumptions used in the development of this attestation are reasonable and are based on generally accepted
actuarial principles, including the appropriate actuarial standards of practice.
I understand and acknowledge that the information being provided in this attestation is being used to obtain Federal
funds.
I agree to maintain and make available reports, working documents and other records as required under 42 C.F.R.
423.§888(d). This includes information about data and/or assumptions I may have relied upon.
I certify that this attestation is true and accurate to the best of my knowledge and belief.
Electronic Signature

OMB Approval # 0

An asterisk (*) identifies a required field.

OMB Approval # 0

PART IV.
1) *Bank Name:
2) *Bank Address:
*Street 1
Street 2
*City

*State/US Territory

*Zip Code

3) *Account Number:
4) *Name of Organization Associated with Account:
5) *Account type: Checking Account

Savings Account

6) *Bank Routing Number:
7) *Bank Contact *First Name

Middle Initial:

*Last Name:

8) E-mail address:
9) *Telephone Number:

An asterisk (*) identifies a required field.

PART V.
Payment Frequency will default to Monthly for all RDS applications.

OMB Approval # 0

An asterisk (*) identifies a required field.

OMB Approval # 0

PART VI.
A. Retiree Data Electronic Data Interchange (EDI) Method
Note: The Plan Sponsor must provide the EDI details for each benefit option. These fields may be applied to multiple
benefit options or may be filled in for each benefit option individually.
1) * Retiree List Submission and Response Method
RDS Secure Website to RDS Center
Plan Sponsor or Vendor Mainframe to RDS Center Mainframe
Plan Sponsor or Vendor Mainframe to RDS Center Mainframe
with a copy of all Retiree Response files sent to the RDS
Secure Website
Voluntary Data Sharing Agreement (VDSA) via the Coordination of Benefits (COB) Contractor
2)* Vendor ID or VDSA Plan Number or MIR Reporter ID (not required for RDS Secure Website to RDS
Center):
3) *Name of Organization Submitting Retiree List
4) *Technical Contact: First Name:

Middle Initial:

*Last Name:

5)*E-mail Address:
6) *Re-Enter E-mail Address:
7) *Telephone Number:

ext

8)FAX Number :

9)* Address:
* Street Line 1
Street Line 2
*City

*State/US Territory

*Zip Code

10)*Method of retiree notification file transmission (will be limited to the retiree list submission and response
method)
RDS Secure Website
RDS Center Mainframe to Plan Sponsor or Vendor Mainframe
Voluntary Data Sharing Agreement (VDSA) or Mandatory Insurer Reporting (MIR) via the Coordination of
Benefits (COB) Contractor
B. Retiree List

An asterisk (*) identifies a required field.

Plan Sponsors must submit an electronic list of retirees for whom they are seeking subsidy payments. For each retiree
the following data elements must be provided:
•
•
•
•

Application ID (assigned to you by the RDS Center)
Unique Benefit Option Identifier – This should be the same as the Unique Benefit Option Identifier entered in
Part II (B).
Effective Date – This should either be the first day of the Plan Year or the first date of coverage for the Retiree
under the Plan, whichever is later.
Termination Date – The last date of coverage for the Retiree under the Plan, if known. If unknown, leave it

OMB Approval # 0

An asterisk (*) identifies a required field.

•
•
•
•
•
•
•
•
•

blank.
First name
Last name
Middle initial (optional)
Social Security Number (SSN)
Medicare beneficiary identifier (HICN or MBI)
Date of Birth
Gender
Relationship to the Retiree (self, spouse, dependent)
Transaction Type (add, update, delete)

OMB Approval # 0

An asterisk (*) identifies a required field.

PART VII
1.

Compliance. In order to receive subsidy payment(s), Plan Sponsor agrees to comply with all of the terms and
conditions of 42 C.F.R. §423Subpart R and in other guidance issued by CMS, including, but not limited to, the
conditions for submission of data for obtaining payment and the record retention requirements.

Notice of Creditable Coverage: Plan Sponsor certifies that it has provided or will provide prior to the beginning
of the plan year referenced in this Plan Sponsor application, creditable coverage notices in accordance with 42
C.F.R. §423.56 to Part D eligible individuals covered under the Plan Sponsor’s plan.

Written Agreement: Plan Sponsor certifies that, prior to the first day of the plan year specified in this Plan
Sponsor application, it has executed a written agreement with its health insurance issuer or group health plan
regarding disclosure of information to CMS, and the issuer or plan agrees to disclose to CMS, on behalf of the
Plan Sponsor, the information necessary for the Plan Sponsor to comply with the requirements of the RDS
Program.
Use of Records: Plan Sponsor understands and agrees that officers, employees and contractors of the
Department of Health and Human Services, including the Office of Inspector General (OIG), may use information
collected under the RDS Program only for the purposes of, and to the extent necessary in, carrying out their
responsibilities under 42 C.F.R. §423 Subpart R including, but not limited to, determination of payments and
payment-related oversight and program integrity activities, or as otherwise required by law. This restriction does
not limit OIG authority to conduct audits and evaluations necessary for purposes of 42 C.F.R. §423 Subpart R or
other authority. Sponsors further acknowledge that CMS will release Retiree Drug Subsidy payment data
in accordance with 423.884(c).

Obtaining Federal Funds: Plan Sponsor acknowledges that the information furnished in its Plan Sponsor
application is being provided to obtain Federal funds. Plan Sponsor certifies that it requires all subcontractors,
including plan administrators, to acknowledge that information provided in connection with the subcontract is used
for purposes of obtaining Federal funds. Plan Sponsor acknowledges that payment of a subsidy is conditioned on
the submission of accurate information. Plan Sponsor agrees that it will not knowingly present or cause to be
presented a false or fraudulent claim. Plan Sponsor acknowledges that any overpayment made to the Plan
Sponsor under the RDS program, or any debt that arises from such overpayment, may be recovered by CMS.
Plan Sponsor will promptly update any changes to the information submitted in its Plan Sponsor application. If
Plan Sponsor becomes aware that information in this application is not (or is no longer) true, accurate and
complete, Plan Sponsor agrees to notify CMS promptly of this fact.
Data Security: Plan Sponsor agrees to establish and implement proper safeguards against unauthorized use and
disclosure of the data exchanged under this Plan Sponsor application. Plan Sponsor recognizes that the use and
disclosure of protected health information (PHI) is governed by the Health Insurance Portability and Accountability
Act (HIPAA) and accompanying regulations. Plan Sponsor certifies that its retiree group health plan(s) has
established and implemented appropriate safeguards in compliance with 45 C.F.R. Parts 160, 162 and 164
(HIPAA administrative simplification, privacy and security rule) in order to prevent unauthorized disclosure of such
information or data. Sponsor also agrees that if it participates in the administration of the plan(s), then it has also
established and implemented the same safeguards in compliance with the above HIPAA citations. Any and all
Plan Sponsor personnel interacting with PHI shall be advised of (1) the confidential nature of the information; (2)
safeguards required to protect the information, and (3) the administrative, civil and criminal penalties for
noncompliance contained in applicable Federal laws.
Depository Information: Plan Sponsor hereby authorizes CMS to initiate payment, credit entries and other
adjustments, including offsets and requests for payment, in accordance with the provisions of 42 C.F.R. §423
Subpart R and applicable provisions of 45 CFR Part 30, to the account at the financial institution (hereinafter the
“Depository”) indicated under the Electronic Funds Transfer (EFT) section of the Plan Sponsor application. Plan
Sponsor agrees to immediately pay back any overpayment or debt upon notification from CMS of the
overpayment or debt. Plan Sponsor agrees to promptly update any changes in its Depository information.

OMB Approval # 0

An asterisk (*) identifies a required field.

Change of Ownership: The Plan Sponsor shall provide written notice to CMS at least 60 days prior to a change in
ownership, as defined in 42 CFR §423.892(a). When a change of ownership results in a transfer of the liability for
prescription drug costs, this Plan Sponsor Agreement is automatically assigned to the new owner, who shall be
subject to the terms and conditions of this Plan Sponsor Agreement.

PART VIII.
Signature of Plan Sponsor Authorized Representative
I, the undersigned Authorized Representative of Plan Sponsor, declare that I have examined this Plan Sponsor
Application and Plan Sponsor Agreement. My signature legally and financially binds the Plan Sponsor to the laws,
regulations, and other guidance applicable to the RDS program (including, but not limited to 42 C.F.R.§423 Subpart R)
and all other applicable laws and regulations. I certify that the information contained in this Plan Sponsor Application and
Plan Sponsor Agreement is true, accurate and complete to the best of my knowledge and belief, and I authorize CMS to
verify this information. I understand that, because payment of a subsidy will be made from Federal funds, any false
statements, documents, or concealment of a material fact is subject to prosecution under applicable Federal and/or State
law. If I become aware that information in this application is not (or is no longer) true, accurate and complete, I
agree to notify CMS promptly of this fact.

□ Electronic Signature

OMB Approval # 0

File Type	application/pdf
File Title	RDS Application
Subject	RDS Application
Author	CMS
File Modified	2020-05-11
File Created	2020-05-08