Medicare Forms
2024 BlueMedicare Patriot (PPO)
View and download important forms and documents about your BlueMedicare plan from Florida Blue.
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H5434-038 - Lake, Sumter, Marion
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H5434-040 - Bay, Calhoun, Escambia, Franklin, Gadsden, Jefferson, Leon, Liberty, Okaloosa, Santa Rosa, Wakulla, Walton
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H5434-041 - Alachua, Clay, Duval, Nassau, St. Johns
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H5434-042 - Charlotte, Collier, Hernando, Highlands, Hillsborough, Lee, Manatee, Pasco, Pinellas, Sarasota, Citrus, Polk
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H5434-044 - Brevard, Flagler, Orange, Osceola, Seminole, Volusia, Indian River, Martin, Palm Beach, St. Lucie
| 2024 Annual Notice of Changes | Last Updated |
|---|---|
| 2024 Annual Notice of Changes - Lake, Marion and Sumter | 9/18/2023 |
| 2024 Annual Notice of Changes - Bay, Escambia, Okaloosa, Santa Rosa and Walton | 9/18/2023 |
| 2024 Annual Notice of Changes - Clay, Duval, Nassau and St. Johns | 9/18/2023 |
| 2024 Annual Notice of Changes - Hillsborough, Pasco and Pinellas | 9/18/2023 |
| 2024 Annual Notice of Changes - Brevard and Orange | 9/18/2023 |
| 2024 Enrollment Form | Last Updated |
|---|---|
| 2024 Enrollment Form | 9/8/2023 |
| 2024 Medicare Star Rating | Last Updated |
|---|---|
| 2024 Medicare Star Rating | 10/12/2022 |
2023 BlueMedicare Patriot (PPO)
View and download important forms and documents about your BlueMedicare plan from Florida Blue.
-
H5434-038 - Lake, Sumter, Marion
-
H5434-040 - Bay, Escambia, Okaloosa, Santa Rosa, Walton
-
H5434-041 - Clay, Duval, Nassau, St. Johns
-
H5434-042 - Hillsborough, Pasco, Pinellas
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H5434-044 - Brevard, Orange
| Plan Document | Last Updated |
|---|---|
| 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 |
| Plan Document | Last Updated |
|---|---|
| 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 |
| Plan Document | Last Updated |
|---|---|
| 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 |
| Plan Document | Last Updated |
|---|---|
| 2023 Enrollment Form | last updated 8/11/2022 |
| Plan Document | Last Updated |
|---|---|
| 2023 Medicare Star Rating | last updated 10/12/2022 |