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 Texas.
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 03/01/2023
- 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 03/01/2023
- 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 03/01/2023
- 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 03/01/2023
- 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 03/01/2023
- 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 03/01/2023
- 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 03/01/2023
- 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 03/01/2023
- 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- 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 03/01/2023
- 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 03/01/2023
- 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- 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 03/01/2023
- 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 03/01/2023
- Prescription Drug Coverage Determination Request Form (PDP)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (PDP) – Last Updated 09/30/2022
Other
Last Updated: March 10, 2023
Last Updated: 09302022
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