2022 Summary of Benefits
Summary of Benefits - Pinellas (PDF)
Summary of Benefits - Hernando & Pasco (PDF)
Summary of Benefits - Bay, Escambia, Leon, Okaloosa, Santa Rosa, Walton (PDF)
Summary of Benefits - Clay, Duval, Nassau, St. Johns, Flagler, Volusia (PDF)
Summary of Benefits - Broward, Indian River, Martin, Miami-Dade, Palm Beach, St. Lucie (PDF)
Summary of Benefits - Highlands, Manatee, Sarasota (PDF)
Summary of Benefits - Charlotte, Collier, Lee (PDF)
Summary of Benefits - Brevard, Orange, Osceola, Seminole (PDF)
Summary of Benefits - Hillsborough, Polk (PDF)
Summary of Benefits - Lake, Marion, Sumter (PDF)
Summary of Benefits - Alachua, Citrus (PDF)
2022 Evidence of Coverage
Evidence of Coverage - Pinellas (PDF)
Evidence of Coverage - Highlands, Manatee, Sarasota (PDF)
Evidence of Coverage - Bay, Escambia, Leon, Okaloosa, Santa Rosa, Walton (PDF)
Evidence of Coverage - Broward, Indian River, Martin, Palm Beach, St. Lucie (PDF)
Evidence of Coverage - Charlotte, Collier, Lee (PDF)
Evidence of Coverage - Clay, Duval, Flagler, Nassau, St Johns, Volusia (PDF)
Evidence of Coverage - Miami-Dade (PDF)
Evidence of Coverage - Brevard, Orange, Osceola, Seminole (PDF)
Evidence of Coverage - Hillsborough, Polk (PDF)
Evidence of Coverage - Hernando, Pasco (PDF)
Evidence of Coverage - Lake, Marion, Sumter (PDF)
Evidence of Coverage - Alachua, Citrus (PDF)
2022 Annual Notice of Change
Annual Notice of Change - Pinellas (PDF)
Annual Notice of Change - Manatee, Sarasota (PDF)
Annual Notice of Change - Escambia, Okaloosa, Santa Rosa (PDF)
Annual Notice of Change - Broward, Indian River, Martin, Palm Beach, St. Lucie (PDF)
Annual Notice of Change - Charlotte, Collier, Lee (PDF)
Annual Notice of Change - Clay, Duval (PDF)
Annual Notice of Change - Miami-Dade (PDF)
Annual Notice of Change - Orange (PDF)
Annual Notice of Change - Hillsborough, Polk (PDF)
Annual Notice of Change - Hernando, Pasco (PDF)
Annual Notice of Change - Lake, Marion, Sumter (PDF)
2022 Comprehensive Formulary
Comprehensive Formulary – Alachua, Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Flagler, Hernando, Highlands, Hillsborough, Indian River, Lake, Lee, Leon, Manatee, Marion, Martin, Miami-Dade, Nassau, Orange, Osceola, Okaloosa, Palm Beach, Pasco, Pinellas, Polk, Santa Rosa, Sarasota, Seminole, St. Johns, St. Lucie, Sumter, Volusia, Walton (PDF)
2022 Other Information and Documents
Enrollment Form (PDF)
Service Area Map (PDF)
Medicare Star Rating (PDF)
Low-Income Subsidy - Medicare Extra Help Program (PDF)
Prescription Drug Transition Policy (PDF)
2021 Plan Documents
2021 Summary of Benefits
Summary of Benefits - Pinellas / Hernando, Pasco (PDF)
Summary of Benefits - Escambia, Okaloosa, Santa Rosa / Clay, Duval (PDF)
Summary of Benefits - Manatee, Sarasota / Charlotte, Collier, Lee (PDF)
Summary of Benefits - Broward, Indian River, Martin, Palm Beach, St. Lucie / Miami-Dade (PDF)
Summary of Benefits - Brevard, Orange, Osceola, Seminole / Hillsborough, Polk (PDF)
Summary of Benefits - Lake, Marion, Sumter (PDF)
2021 Evidence of Coverage
Evidence of Coverage - Pinellas (PDF)
Evidence of Coverage - Manatee, Sarasota (PDF)
Evidence of Coverage - Escambia, Okaloosa, Santa Rosa (PDF)
Evidence of Coverage - Broward, Indian River, Martin, Palm Beach, St. Lucie (PDF)
Evidence of Coverage - Charlotte, Collier, Lee (PDF)
Evidence of Coverage - Clay, Duval (PDF)
Evidence of Coverage - Miami-Dade (PDF)
Evidence of Coverage - Brevard, Orange, Osceola, Seminole (PDF)
Evidence of Coverage - Hillsborough, Polk (PDF)
Evidence of Coverage - Hernando, Pasco (PDF)
Evidence of Coverage - Lake, Marion, Sumter (PDF)
2021 Annual Notice of Change
Annual Notice of Change - Pinellas (PDF)
Annual Notice of Change - Manatee, Sarasota (PDF)
Annual Notice of Change - Escambia, Okaloosa, Santa Rosa (PDF)
Annual Notice of Change - Broward, Indian River, Martin, Palm Beach, St. Lucie (PDF)
Annual Notice of Change - Charlotte, Collier, Lee (PDF)
Annual Notice of Change - Clay, Duval (PDF)
Annual Notice of Change - Miami-Dade (PDF)
Annual Notice of Change - Brevard, Orange, Osceola, Seminole (PDF)
Annual Notice of Change - Hillsborough, Polk (PDF)
Annual Notice of Change - Hernando, Pasco (PDF)
2021 Comprehensive Formulary
Comprehensive Formulary - Pinellas / Manatee, Sarasota / Escambia, Okaloosa, Santa Rosa / Broward, Indian River, Martin, Palm Beach, St. Lucie / Charlotte, Collier, Lee / Clay, Duval / Miami-Dade / Brevard, Orange, Osceola, Seminole / Hillsborough, Polk / Hernando, Pasco / Lake, Marion, Sumter (PDF)
2021 Other Information and Documents
Enrollment Form (PDF)
Service Area Map (PDF)
Medicare Star Rating (PDF)
Low-Income Subsidy - Medicare Extra Help Program (PDF)
Prescription Drug Transition Policy (PDF)
FBM FORM BMV PPO 003 NF 102021
Last Updated: 10.01.2021
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