Medicare Advantage Plan Documents
Find the documents you need to manage your Medicare Advantage Prescription Drug plan offered by Blue Cross and Blue Shield of Oklahoma.
View these forms and documents in Spanish. If you have questions, please Contact Us.
Oklahoma City Area
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
Sherman and Ada Areas
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
Tulsa Area
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
Wichita Falls and Lawton Areas
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
Last Updated: Feb. 28, 2023
Last Updated: 09302022
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