BlueMedicare Classic (HMO)

2022 Summary of Benefits

Summary of Benefits - Miami-Dade (PDF)

Summary of Benefits - Palm Beach (PDF)

Summary of Benefits - Bay, Brevard, Charlotte, Collier, Escambia, Lake, Lee, Manatee, Marion, Martin, Okaloosa, Santa Rosa, Sarasota, St. Johns, St. Lucie, Sumter (PDF)

Summary of Benefits - Citrus (PDF)

Summary of Benefits - Orange, Osceola, Seminole (PDF)

Summary of Benefits - Broward (PDF)

Summary of Benefits - Clay, Duval (PDF)

Summary of Benefits - Hernando, Hillsborough, Pasco, Polk (PDF)

 

2022 Evidence of Coverage

Evidence of Coverage - Miami-Dade (PDF)

Evidence of Coverage - Palm Beach (PDF)

Evidence of Coverage - Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Lake, Lee, Manatee, Marion, Martin, Okaloosa, Santa Rosa, Sarasota, St. Johns, St. Lucie, Sumter (PDF)

Evidence of Coverage - Orange, Osceola, Seminole (PDF)

Evidence of Coverage - Hernando, Hillsborough, Pasco, Polk (PDF)

 

2022 Annual Notice of Change

Annual Notice of Change - Miami-Dade (PDF)

Annual Notice of Change - Palm Beach (PDF)

Annual Notice of Change - Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Lake, Lee, Manatee, Marion, Martin, Okaloosa, Santa Rosa, Sarasota, St. Johns, St. Lucie, Sumter (PDF)

Annual Notice of Change - Orange, Osceola, Seminole (PDF)

Annual Notice of Change - Hernando, Hillsborough, Pasco, Polk (PDF)

 

2022 Comprehensive Formulary

Comprehensive Formulary - Miami-Dade (PDF)

Comprehensive Formulary - Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Hernando, Hillsborough, Lake, Lee, Manatee, Marion, Martin, Okaloosa, Orange, Osceola, Palm Beach, Pasco, Polk, Santa Rosa, Sarasota, Seminole, St. Johns, St. Lucie, Sumter (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 Summary of Benefits

Summary of Benefits - Hernando, Hillsborough, Pasco, Polk (PDF)

Summary of Benefits - Miami-Dade (PDF)

Summary of Benefits - Orange, Osceola, Seminole (PDF)

Summary of Benefits - Palm Beach (PDF)

Summary of Benefits - Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Lake, Lee, Manatee, Marion, Martin, Okaloosa, Santa Rosa, Sarasota, St. Johns, St. Lucie, Sumter (PDF)

 

2021 Evidence of Coverage

Evidence of Coverage - Miami-Dade (PDF)

Evidence of Coverage - Palm Beach (PDF)

Evidence of Coverage - Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Lake, Lee, Manatee, Marion, Martin, Okaloosa, Santa Rosa, Sarasota, St. Johns, St. Lucie, Sumter (PDF)

Evidence of Coverage - Orange, Osceola, Seminole (PDF)

Evidence of Coverage - Hernando, Hillsborough, Pasco, Polk (PDF)

 

2021 Annual Notice of Change

Annual Notice of Change - Miami-Dade (PDF)

Annual Notice of Change - Palm Beach (PDF)

Annual Notice of Change - Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Lake, Lee, Manatee, Marion, Martin, Okaloosa, Santa Rosa, Sarasota, St. Johns, St. Lucie, Sumter (PDF)

Annual Notice of Change - Orange, Osceola, Seminole (PDF)

Annual Notice of Change - Hernando, Hillsborough, Pasco, Polk (PDF)

 

2021 Comprehensive Formulary

Comprehensive Formulary - Miami-Dade (PDF)

Comprehensive Formulary - Palm Beach (PDF)

Comprehensive Formulary - Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Lake, Lee, Manatee, Marion, Martin, Okaloosa, Santa Rosa, Sarasota, St. Johns, St. Lucie, Sumter / Orange, Osceola, Seminole / Hernando, Hillsborough, Pasco, Polk (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 H1035
Last Updated: 10.01.2021
Y0011_FBM1080