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.
All Oklahoma Areas
-
Blue Cross Medicare Advantage Flex (PPO)SM
2022 Evidence of Coverage Flex (PPO) English | español
2022 Summary of Benefits Flex (PPO) English | español
2022 Enrollment Form (PPO) English | español
2022 Drug Formulary Flex (PPO) English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (MAPD PPO) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (MAPD) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (MAPD) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
-
Blue Cross Medicare Advantage Classic (PPO)SM
2022 Evidence of Coverage Classic (PPO) English | español
2022 Summary of Benefits Classic (PPO) English | español
2022 Enrollment Form (PPO) English | español
2022 Drug Formulary Classic (PPO) English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (MAPD PPO) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (MAPD) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (MAPD) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
Oklahoma City Area
-
Blue Cross Medicare Advantage Basic (HMO)SM
2022 Annual Notice of Change Basic (HMO) English | español
2022 Evidence of Coverage Basic (HMO) English | español
2022 Summary of Benefits Basic (HMO) English | español
2022 Enrollment Form (HMO) English | español
2022 Plan Star Rating (HMO) English | español
2022 Drug Formulary Basic (HMO) English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (MAPD HMO) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (MAPD) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (MAPD) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
-
Blue Cross Medicare Advantage Classic (PPO)SM
2022 Evidence of Coverage Classic (PPO) English | español
2022 Summary of Benefits Classic (PPO) English | español
2022 Enrollment Form (PPO) English | español
2022 Drug Formulary Classic (PPO) English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (MAPD PPO) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (MAPD) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (MAPD) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
Last Updated: 09302021
Y0096_WEBOKMM22