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
Important 2023 benefit information, last updated 2/14/2023
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
| 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 |
2023 Evidence of Coverage
| 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 |
2023 Summary of Benefits
| 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 |
2023 Enrollment Form
| Plan Document | Last Updated |
|---|---|
| 2023 Enrollment Form | last updated 8/11/2022 |
2023 Medicare Star Rating
| Plan Document | Last Updated |
|---|---|
| 2023 Medicare Star Rating | last updated 10/12/2022 |