Prescription Drug Plan Documents
Find the documents you need to help you manage your prescription drug plan offered by Blue Cross and Blue Shield of Oklahoma.
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Blue Cross MedicareRx Basic (PDP)SM
2022 Annual Notice of Change Basic (PDP) English | español
2022 Evidence of Coverage Basic (PDP) English | español
2022 Summary of Benefits (PDP) English | español
2022 Enrollment Form (PDP) English | español
2022 Plan Star Rating (PDP) English | español
2022 Drug Formulary Basic (PDP) English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (PDP) English | español
2022 Prescription Drug Transition Policy (PDP) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PDP) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PDP) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (PDP)
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Blue Cross MedicareRx Value (PDP)SM
2022 Annual Notice of Change Value (PDP) English | español
2022 Evidence of Coverage Value (PDP) English | español
2022 Summary of Benefits (PDP) English | español
2022 Enrollment Form (PDP) English | español
2022 Plan Star Rating (PDP) English | español
2022 Drug Formulary Value (PDP) English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (PDP) English | español
2022 Prescription Drug Transition Policy (PDP) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PDP) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PDP) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (PDP)
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Blue Cross MedicareRx Choice (PDP)SM
2022 Annual Notice of Change Choice (PDP) English | español
2022 Evidence of Coverage Choice (PDP) English | español
2022 Summary of Benefits (PDP) English | español
2022 Enrollment Form (PDP) English | español
2022 Plan Star Rating (PDP) English | español
2022 Drug Formulary Choice (PDP) English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (PDP) English | español
2022 Prescription Drug Transition Policy (PDP) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PDP) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PDP) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (PDP)
Last Updated: 12312021
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