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
2019 Annual Notice of Change Basic (PDP) English | español
2019 Evidence of Coverage Basic (PDP) English | español
2019 Summary of Benefits (PDP) English | español
2019 Enrollment Form (PDP) English | español
2019 Plan Star Rating (PDP) English | español
2019 Drug Formulary Basic (PDP) English | español
2019 Pharmacy Directory Basic (PDP) English | español
2019 Low Income Premium Subsidy (PDP) English | español
2019 Prescription Drug Transition Policy (PDP) English | español
2019 Directory Online Request Form English | español
2019 Prescription Drug Coverage Determination Request Form (PDP)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (PDP)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (PDP)
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Blue Cross MedicareRx Value (PDP)SM
2019 Annual Notice of Change Value (PDP) English | español
2019 Evidence of Coverage Value (PDP) English | español
2019 Summary of Benefits (PDP) English | español
2019 Enrollment Form (PDP) English | español
2019 Plan Star Rating (PDP) English | español
2019 Drug Formulary Value (PDP) English | español
2019 Pharmacy Directory Value (PDP) English | español
2019 Low Income Premium Subsidy (PDP) English | español
2019 Prescription Drug Transition Policy (PDP) English | español
2019 Directory Online Request Form English | español
2019 Prescription Drug Coverage Determination Request Form (PDP)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (PDP)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (PDP)
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Blue Cross MedicareRx Plus (PDP)SM
2019 Annual Notice of Change Plus (PDP) English | español
2019 Evidence of Coverage Plus (PDP) English | español
2019 Summary of Benefits (PDP) English | español
2019 Enrollment Form (PDP) English | español
2019 Plan Star Rating (PDP) English | español
2019 Drug Formulary Plus (PDP) English | español
2019 Pharmacy Directory Plus (PDP) English | español
2019 Low Income Premium Subsidy (PDP) English | español
2019 Prescription Drug Transition Policy (PDP) English | español
2019 Directory Online Request Form English | español
2019 Prescription Drug Coverage Determination Request Form (PDP)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (PDP)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (PDP)
Last Updated: 09302018
Y0096_WEB_NM_MM19 Accepted
Last Updated: 09302018
Y0096_WEB_OK_MM19 Accepted