Medicare Forms
2024 BlueMedicare Complete (HMO D-SNP)
View and download important forms and documents about your BlueMedicare plan from Florida Blue.
-
H1035-027 - Miami-Dade
-
H1035-028 - Broward, Palm Beach, St. Lucie
-
H1035-029 - Brevard, Lake, Orange, Osceola, Seminole, Sumter
-
H1035-031 - Clay, Duval, Marion
-
H1035-032 - Charlotte, Collier, Hernando, Lee, Manatee, Pasco, Pinellas, Sarasota
-
H1035-050 - Escambia, Okaloosa, Santa Rosa, Walton
| 2024 Annual Notice of Changes | Last Updated |
|---|---|
| 2024 Annual Notice of Changes - Miami-Dade | 10/9/2023 |
| 2024 Annual Notice of Changes - Broward, Palm Beach and St. Lucie | 10/9/2023 |
| 2024 Annual Notice of Changes - Brevard, Lake, Orange, Osceola, Seminole and Sumter | 10/9/2023 |
| 2024 Annual Notice of Changes - Hillsborough and Polk | 10/9/2023 |
| 2024 Annual Notice of Changes - Clay, Duval and Marion | 10/9/2023 |
| 2024 Annual Notice of Changes - Charlotte, Collier, Hernando, Lee, Manatee, Pasco, Pinellas and Sarasota | 10/9/2023 |
| 2024 Annual Notice of Changes - Escambia, Okaloosa, Santa Rosa and Walton | 10/9/2023 |
| 2024 Evidence of Coverage | Last Updated |
|---|---|
| 2024 Evidence of Coverage - Miami-Dade | 10/4/2023 |
| 2024 Evidence of Coverage - Broward, Palm Beach and St. Lucie | 10/4/2023 |
| 2024 Evidence of Coverage - Brevard, Lake, Orange, Osceola, Seminole and Sumter | 10/4/2023 |
| 2024 Evidence of Coverage - Clay, Duval and Marion | 10/4/2023 |
| 2024 Evidence of Coverage - Charlotte, Collier, Hernando, Lee, Manatee, Pasco, Pinellas and Sarasota | 10/4/2023 |
| 2024 Evidence of Coverage - Escambia, Okaloosa, Santa Rosa and Walton | 10/4/2023 |
| 2024 Enrollment Form | Last Updated |
|---|---|
| 2024 Enrollment Form | 9/1/2023 |
| 2024 Medicare Star Rating | Last Updated |
|---|---|
| 2024 Medicare Star Rating | 10/22/2023 |
| 2024 Prescription Drug Transition Policy | Last Updated |
|---|---|
| 2024 Prescription Drug Transition Policy | 09/20/2023 |
| 2024 Low-Income Subsidy - Extra Help Program | Last Updated |
|---|---|
| 2024 Low-Income Subsidy - Extra Help Program | 09/11/2023 |
2023 BlueMedicare Complete (HMO D-SNP)
View and download important forms and documents about your BlueMedicare plan from Florida Blue.
-
H1035-027 - Miami-Dade
-
H1035-028 - Broward, Palm Beach, St. Lucie
-
H1035-029 - Brevard, Lake, Orange, Osceola, Seminole, Sumter
-
H1035-030 - Hillsborough, Polk
-
H1035-031 - Clay, Duval, Marion
-
H1035-032 - Charlotte, Collier, Hernando, Lee, Manatee, Pasco, Pinellas, Sarasota
-
H1035-050 - Escambia, Okaloosa, Santa Rosa, Walton
| 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 |
| 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 |
| 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 | last updated 8/23/2022 |
| 2023 Summary of Benefits - Brevard, Lake, Orange, Osceola, Seminole, Sumter | last updated 8/23/2022 |
| Plan Document | Last Updated |
|---|---|
| 2023 Comprehensive Formulary | last updated 11/20/2023 |
| Plan Document | Last Updated |
|---|---|
| 2023 Enrollment Form | last updated 8/15/2022 |
| Plan Document | Last Updated |
|---|---|
| 2023 Medicare Star Rating | last updated 10/12/2022 |
| Plan Document | Last Updated |
|---|---|
| 2023 Prescription Drug Transition Policy | last updated 7/1/2022 |
| Plan Document | Last Updated |
|---|---|
| 2023 Low-Income Subsidy - Extra Help Program | last updated 9/23/2022 |