Medicare Forms
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BlueMedicare Patriot (PPO)
2023 Service Area
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H5434-038 - Lake, Sumter, Marion
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H5434-040 - Bay, Escambia, Okaloosa, Santa Rosa, Walton
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H5434-041 - Clay, Duval, Nassau, St. Johns
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H5434-042 - Hillsborough, Pasco, Pinellas
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H5434-044 - Brevard, Orange
BlueMedicare Patriot (PPO)
2023 Plan Documents
View and download important forms and documents about your BlueMedicare plan from Florida Blue.
2023 Annual Notice of Changes
- 2023 Annual Notice of Changes - Lake, Marion, Sumter, last updated 8/22/2022
- 2023 Annual Notice of Changes - Bay, Escambia, Okaloosa, Santa Rosa, Walton, last updated 8/22/2022
- 2023 Annual Notice of Changes - Clay, Duval, Nassau, St. Johns, last updated 8/22/2022
- 2023 Annual Notice of Changes - Hillsborough, Pasco, Pinellas, last updated 8/22/2022
- 2023 Annual Notice of Changes - Brevard, Orange, last updated 8/22/2022
2023 Evidence of Coverage
- 2023 Evidence of Coverage - Lake, Marion, Sumter, last updated 8/30/2022
- 2023 Evidence of Coverage - Bay, Escambia, Okaloosa, Santa Rosa, Walton, last updated 8/30/2022
- 2023 Evidence of Coverage - Clay, Duval, Nassau, St. Johns, last updated 8/30/2022
- 2023 Evidence of Coverage - Hillsborough, Pasco, Pinellas, last updated 8/30/2022
- 2023 Evidence of Coverage - Brevard, Orange, last updated 8/30/2022
2023 Summary of Benefits
- 2023 Summary of Benefits - Pinellas, last updated 9/12/2022
- 2023 Summary of Benefits - Pasco, last updated 9/12/2022
- 2023 Summary of Benefits - Bay, Escambia, Okaloosa, Santa Rosa, Walton, last updated 9/12/2022
- 2023 Summary of Benefits - Clay, Duval, Nassau, St. Johns, last updated 9/12/2022
- 2023 Summary of Benefits - Brevard, Orange, last updated 9/12/2022
- 2023 Summary of Benefits - Hillsborough, last updated 9/12/2022
- 2023 Summary of Benefits - Lake, Marion, Sumter, last updated 9/12/2022
2023 Enrollment Form
- 2023 Enrollment Form, last updated 8/11/2022
2023 Medicare Star Rating
- 2023 Medicare Star Rating, last updated 10/12/2022
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