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Plan65 Information Request Form

Blue Cross and Blue Shield of Oklahoma will send you a packet of information about Plan65.

Look over the materials and decide which Medicare supplement plan best suits your needs.

What to do:
Simply complete the form below, and a Plan65 informational packet will be sent to you shortly.

Your information:                                    *Optional Information
Name:    
Address:   
City:  
State:   Zip:
Phone number:  
Age:          Date of Birth:
(mm/dd/yyyy)
*E-mail address:
Do you currently have another Medicare supplement plan? Yes No
*If yes, which company?
Are you currently a Blue Cross and Blue Shield of Oklahoma member? Yes No

You may apply for Plan65 coverage if:

  • You have Medicare Part A and B and;
  • You are an Oklahoma resident and;
  • You are age 65 or older.
 
      

If you would like to speak to one of our health insurance representatives,
call toll-free at 1-800-522-9266.