Is This Plan Right For Me?

Medi-Pak Rx^® is a Medicare Part D prescription drug plan. With Medi-Pak Rx, you can choose from three different plans, so you can pick the coverage that's right for you. To enroll in Medi-Pak Rx, you must be entitled to Medicare Part A or enrolled in Medicare Part B and live in Arkansas.

Important Information About Our Plan

Details about our plans are included in the information below.

• Summary of Benefits (205 KB PDF)
  
• Evidence of Coverage
  
• Pharmacy Directory (956 KB PDF)
  
• Low-Income Subsidy Table (41 KB PDF)
  
• Drug Transition Policy (What if my drug is not on the formulary?) (39 KB PDF)
  
• Appeals and Grievances (72 KB PDF)
  
• Quality Assurance Policies & Procedures (55 KB PDF)
  
• Rights & Responsibilities Upon Disenrollment (55 KB PDF)
  
• Privacy Notice (21 KB PDF)
  

You may qualify for extra help with your monthly premium and drug costs.

Forms that may assist you

• Medicare Prescription Drug Determination Request Form
  
• Medicare Part D Coverage Determination Request Form (for providers)
  
• Can I Appoint a Representative?
  
• Designate someone to ask questions on my behalf (6 KB PDF)
  

For More Information

If you would like to talk to someone about a Medi-Pak Rx plan, call 1-800-392-2583 (8 a.m. - 5 p.m.) or send us an e-mail at questions@arkbluecross.com. TTY users may call 1-800-370-5869.

Order Free Information Packet

The materials on this Web site are available in alternative formats for the visually impaired by calling 1-800-634-6314 (TTY users should call 1-800-370-5869).

S5795_Rx Website Submission

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