Excellus BlueCross BlueShield | Employer eNewsletter

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Your Name

First and Last name

Group Name

Name of your group

Group Number

8-digits including leading 0's

Form 5500 Plan Number

The 3-digit plan number reported on the IRS Form 5500 filed with US DOL.

Total dollar amount the business contributed for Group medical and pharmacy insurance (prior calendar year)

Total dollar amount = premium or premium equivalent minus what is deducted from employee payroll.

Is this information for a self-funded plan sponsor or minimum premium plan?

Yes

Total Third Party Administrator (TPA) fees paid to parties other than Excellus BlueCross BlueShield (prior calendar year)

Includes costs in addition to Excellus BCBS admin fee that are taken into account for purposes of calculating COBRA premiums

Is your Stop Loss Coverage with Excellus BCBS?

Yes

Submit

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