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.
View these forms and documents in Spanish. If you have questions, please Contact Us.
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Blue Cross MedicareRx Basic (PDP)SM
General Plan Information- Annual Notice of Change (PDP) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (PDP) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PDP) – Last Updated 09/30/2022
- Evidence of Coverage (PDP) – Last Updated 09/30/2022
- Low Income Premium Subsidy (PDP) – Last Updated 09/30/2022
- Plan Star Rating (PDP) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PDP) – Last Updated 11/08/2022
- 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 11/08/2022
- Prescription Drug Coverage Determination Request Form (PDP)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (PDP) – Last Updated 09/30/2022
Other
General Plan Information- Annual Notice of Change (PDP) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (PDP) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PDP) – Last Updated 09/30/2022
- Evidence of Coverage (PDP) – Last Updated 09/30/2022
- Low Income Premium Subsidy (PDP) – Last Updated 09/30/2022
- Plan Star Rating (PDP) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PDP) – Last Updated 11/08/2022
- 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 11/08/2022
- Prescription Drug Coverage Determination Request Form (PDP)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (PDP) – Last Updated 09/30/2022
Other
-
Blue Cross MedicareRx Value (PDP)SM
General Plan Information- Annual Notice of Change (PDP) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (PDP) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PDP) – Last Updated 09/30/2022
- Evidence of Coverage (PDP) – Last Updated 09/30/2022
- Low Income Premium Subsidy (PDP) – Last Updated 09/30/2022
- Plan Star Rating (PDP) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PDP) – Last Updated 11/08/2022
- 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 11/08/2022
- Prescription Drug Coverage Determination Request Form (PDP)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (PDP) – Last Updated 09/30/2022
Other
General Plan Information- Annual Notice of Change (PDP) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (PDP) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PDP) – Last Updated 09/30/2022
- Evidence of Coverage (PDP) – Last Updated 09/30/2022
- Low Income Premium Subsidy (PDP) – Last Updated 09/30/2022
- Plan Star Rating (PDP) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PDP) – Last Updated 11/08/2022
- 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 11/08/2022
- Prescription Drug Coverage Determination Request Form (PDP)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (PDP) – Last Updated 09/30/2022
Other
-
Blue Cross MedicareRx Choice (PDP)SM
General Plan Information- Annual Notice of Change (PDP) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (PDP) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PDP) – Last Updated 09/30/2022
- Evidence of Coverage (PDP) – Last Updated 09/30/2022
- Low Income Premium Subsidy (PDP) – Last Updated 09/30/2022
- Plan Star Rating (PDP) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PDP) – Last Updated 11/08/2022
- 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 11/08/2022
- Prescription Drug Coverage Determination Request Form (PDP)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (PDP) – Last Updated 09/30/2022
Other
General Plan Information- Annual Notice of Change (PDP) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (PDP) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PDP) – Last Updated 09/30/2022
- Evidence of Coverage (PDP) – Last Updated 09/30/2022
- Low Income Premium Subsidy (PDP) – Last Updated 09/30/2022
- Plan Star Rating (PDP) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PDP) – Last Updated 11/08/2022
- 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 11/08/2022
- Prescription Drug Coverage Determination Request Form (PDP)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (PDP) – Last Updated 09/30/2022
Other
-
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)
-
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)
-
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: Nov. 08, 2022
Last Updated: 09302022
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