Medi-Pak Rx (PDP)

Call Us Toll Free


24 hours a day, 7 days a week

TTY Number


Medi-Pak Rx
Mail Code X502

P.O. Box 44348

Detroit, MI 48244-0348

Plan Information

Arkansas Blue Cross and Blue Shield is not accepting new Medi-Pak Rx (PDP) enrollments at this time.


Contact us

Rights & Responsibilities Upon Disenrollment - Basic [pdf, 918 KB]

Rights & Responsibilities Upon Disenrollment - Premier [pdf, 1000 KB]

Appointing or Designating a Representative

EOC Appeals & Grievances - Basic [pdf, 1030 KB]

EOC Appeals & Grievances - Premier [pdf, 1113 KB]

Coverage determination and redetermination form - Basic

Coverage determination and redetermination form - Premier

CMS Model Electronic Complaint Form

Annual Notice of Coverage - Basic [pdf, 1038 KB]

Annual Notice of Coverage - Premier [pdf, 1038 KB]

Medication Therapy Management

Summary of Benefits [pdf, 491 KB]

Evidence of Coverage - Basic [pdf, 1694 KB]

Evidence of Coverage - Premier [pdf, 1644 KB]

Find a Pharmacy - Basic

Find a Pharmacy - Premier

Privacy Notice

Medicare Star Ratings (English or Espanol )

Formulary Exceptions Forms

Prior Authorization Forms - Basic

Prior Authorization Forms - Premier

Request a Pharmacy Directory

Find Medicine - Premier

Find Medicine - Basic

Low-Income Subsidy Table [pdf, 853 KB]

Calculate my prescription drug costs

S5795_PDP 2019 Member Website

Last updated on 10/15/2018