Arkansas Blue Cross and Blue Shield
Enrollment Form
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Enrollment Materials


The enrollment materials include the enrollment instructions and enrollment form, star ratings sheet, summary of benefits and the multi-language interpreter services sheet.


Medi-Pak Rx (PDP) Enrollment Materials


Learn more about enrolling online


Am I eligible to enroll?
Enrollment Instructions
Why should I enroll online?
Need help?
Is this enrollment secure?

Am I eligible to enroll?

You are eligible for Medi-Pak Rx if you:

  • are an Arkansas resident;
  • are entitled to Medicare Part A or enrolled in Medicare Part B (or both); and
  • are in a valid enrollment period.

Enrollment Instructions

When you complete this on-line enrollment you will be asked to:

  • Check the plan in which you want to enroll.
  • Provide basic information such as name, permanent address, date of birth, etc.
  • Provide required information from your Medicare card.
  • Tell us how you want to pay your monthly premium. If you choose Electronic Funds Transfer (EFT), you will be asked to provide the required banking information.
  • Provide answers to some general questions regarding, for example, other coverage.
  • Type your name in the signature section.

Why should I enroll online?

  • Your enrollment will be complete. You must answer every required question before you can submit the enrollment online.
  • You will have confirmation that your enrollment has been received.

Is this enrollment secure?

For protection of your personal information, this section of our site uses 128-bit encryption. Your information is protected by a "secured session" using Secure Socket Layer (SSL) 128-bit encryption technology. SSL is the industry-standard security protocol for encoding sensitive information. Your internet browser can tell you whether or not you are in a Website secured by SSL technology by the presence of a padlock or key somewhere along the bottom of your browser's window. If the lock is closed or the key is unbroken, you are in a secure section of your host's Website.

Important Note: You will need the information provided on your Medicare card to complete this online enrollment form.

You will not be able to save the information you have entered and come back to it, so please make sure you have enough time to complete the whole enrollment form. If there is NO activity after 20 minutes, your session will time out and the information you have entered will be lost.

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