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
2021 Annual Notice of Change Basic (PDP) English | español
2021 Evidence of Coverage Basic (PDP) English | español
2021 Summary of Benefits (PDP) English | español
2021 Plan Star Rating (PDP) English | español
2021 Drug Formulary Basic (PDP) English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (PDP) English | español
2021 Prescription Drug Transition Policy (PDP) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (PDP) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PDP) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (PDP)
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Blue Cross MedicareRx Value (PDP)SM
2021 Annual Notice of Change Value (PDP) English | español
2021 Evidence of Coverage Value (PDP) English | español
2021 Summary of Benefits (PDP) English | español
2021 Plan Star Rating (PDP) English | español
2021 Enrollment Form (PDP) English | español
2021 Drug Formulary Value (PDP) English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (PDP) English | español
2021 Prescription Drug Transition Policy (PDP) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (PDP) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PDP) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (PDP)
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Blue Cross MedicareRx Choice (PDP)SM
2021 Evidence of Coverage Choice (PDP) English | español
2021 Summary of Benefits (PDP) English | español
2021 Plan Star Rating (PDP) English | español
2021 Enrollment Form (PDP) English | español
2021 Drug Formulary Choice (PDP) English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (PDP) English | español
2021 Prescription Drug Transition Policy (PDP) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (PDP) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PDP) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (PDP)
Last Updated: 12312020
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Last Updated: 07312021
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