Medicare Forms
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BlueMedicare Complete (HMO D-SNP)
2023 Service Area
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H1035-027 - Miami-Dade
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H1035-028 - Broward, Palm Beach, St. Lucie
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H1035-029 - Brevard, Lake, Orange, Osceola, Seminole, Sumter
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H1035-030 - Hillsborough, Polk
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H1035-031 - Clay, Duval, Marion
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H1035-032 - Charlotte, Collier, Hernando, Lee, Manatee, Pasco, Pinellas, Sarasota
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H1035-050 - Escambia, Okaloosa, Santa Rosa, Walton
Important 2023 benefit information, last updated 2/14/2023
BlueMedicare Complete (HMO D-SNP)
2023 Plan Documents
View and download important forms and documents about your BlueMedicare plan from Florida Blue.
2023 Annual Notice of Changes
| Plan Document | Last Updated |
|---|---|
| 2023 Annual Notice of Changes - Miami-Dade | last updated 9/19/2022 |
| 2023 Annual Notice of Changes - Broward, Palm Beach, St. Lucie | last updated 9/19/2022 |
| 2023 Annual Notice of Changes - Brevard, Lake, Orange, Osceola, Seminole, Sumter | last updated 9/19/2022 |
| 2023 Annual Notice of Changes - Hillsborough, Polk | last updated 9/19/2022 |
| 2023 Annual Notice of Changes - Clay, Duval, Marion | last updated 9/19/2022 |
| 2023 Annual Notice of Changes - Charlotte, Collier, Hernando, Lee, Manatee, Pasco, Pinellas, Sarasota | last updated 9/19/2022 |
2023 Evidence of Coverage
| Plan Document | Last Updated |
|---|---|
| 2023 Evidence of Coverage - Miami-Dade | last updated 9/13/2022 |
| 2023 Evidence of Coverage - Broward, Palm Beach, St Lucie | last updated 9/13/2022 |
| 2023 Evidence of Coverage - Brevard, Lake, Orange, Osceola, Seminole, Sumter | last updated 9/13/2022 |
| 2023 Evidence of Coverage - Hillsborough, Polk | last updated 9/13/2022 |
| 2023 Evidence of Coverage - Clay, Duval, Marion | last updated 9/13/2022 |
| 2023 Evidence of Coverage - Charlotte, Collier, Hernando, Lee, Manatee, Pasco, Pinellas, Sarasota | last updated 9/13/2022 |
| 2023 Evidence of Coverage - Escambia, Okaloosa, Santa Rosa, Walton | last updated 9/13/2022 |
2023 Summary of Benefits
| Plan Document | Last Updated |
|---|---|
| 2023 Summary of Benefits - Miami-Dade, Broward, Palm Beach, St. Lucie | last updated 8/23/2022 |
| 2023 Summary of Benefits - Hillsborough, Polk, Charlotte, Collier, Hernando, Lee, Manatee, Pasco, Pinellas, Sarasota | last updated 8/23/2022 |
| 2023 Summary of Benefits - Clay, Duval, Marion, Escambia, Okaloosa, Santa Rosa, Walton, Brevard, Lake, Orange, Osceola, Seminole, Sumter | last updated 8/23/2022 |
| 2023 Summary of Benefits - Brevard, Lake, Orange, Osceola, Seminole, Sumter | last updated 8/23/2022 |
2023 Comprehensive Formulary
| Plan Document | Last Updated |
|---|---|
| 2023 Comprehensive Formulary | last updated 5/18/2023 |
2023 Enrollment Form
| Plan Document | Last Updated |
|---|---|
| 2023 Enrollment Form | last updated 8/15/2022 |
2023 Medicare Star Rating
| Plan Document | Last Updated |
|---|---|
| 2023 Medicare Star Rating | last updated 10/12/2022 |
2023 Prescription Drug Transition Policy
| Plan Document | Last Updated |
|---|---|
| 2023 Prescription Drug Transition Policy | last updated 7/1/2022 |
2023 Low-Income Subsidy - Extra Help Program
| Plan Document | Last Updated |
|---|---|
| 2023 Low-Income Subsidy - Extra Help Program | last updated 9/23/2022 |