Medicare Forms
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BlueMedicare Premier (HMO)
2022 Plan Documents
View and download important forms and documents about your BlueMedicare plan from Florida Blue.
2022 Annual Notice of Changes
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2022 Annual Notice of Changes - Palm Beach (PDF), last updated 08/25/2021
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2022 Annual Notice of Changes - Hillsborough, Polk (PDF), last updated 08/25/2021
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2022 Annual Notice of Changes - Miami-Dade (PDF), last updated 08/25/2021
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2022 Annual Notice of Changes - Broward (PDF), last updated 08/25/2021
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2022 Annual Notice of Changes - Orange, Osceola (PDF), last updated 08/25/2021
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2022 Annual Notice of Changes - Clay, Duval (PDF), last updated 08/25/2021
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2022 Annual Notice of Changes - Hernando, Pasco, Pinellas (PDF), last updated 08/25/2021
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2022 Annual Notice of Changes - Lake, Marion, Sumter (PDF), last updated 08/25/2021
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2022 Annual Notice of Changes - Manatee, Sarasota (PDF), last updated 08/25/2021
2022 Evidence of Coverage
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2022 Evidence of Coverage - Palm Beach (PDF), last updated 08/28/2021
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2022 Evidence of Coverage - Hillsborough, Polk (PDF), last updated 08/28/2021
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2022 Evidence of Coverage - Miami-Dade (PDF), last updated 08/28/2021
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2022 Evidence of Coverage - Broward (PDF), last updated 08/28/2021
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2022 Evidence of Coverage - Orange, Osceola, Seminole (PDF), last updated 08/28/2021
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2022 Evidence of Coverage - Clay, Duval (PDF), last updated 08/28/2021
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2022 Evidence of Coverage - Hernando, Pasco, Pinellas (PDF), last updated 08/28/2021
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2022 Evidence of Coverage - Charlotte, Collier, Lee, Manatee, Sarasota (PDF), last updated 08/28/2021
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2022 Evidence of Coverage - Lake, Marion, Sumter (PDF), last updated 08/28/2021
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2022 Evidence of Coverage - Brevard, St. Lucie (PDF), last updated 08/28/2021
2022 Summary of Benefits
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2022 Summary of Benefits - Miami-Dade (PDF), last updated 08/24/2021
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2022 Summary of Benefits - Palm Beach (PDF), last updated 08/24/2021
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2022 Summary of Benefits - Orange, Osceola, Seminole (PDF),last updated 08/24/2021
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2022 Summary of Benefits - Broward (PDF), last updated 08/24/2021
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2022 Summary of Benefits - Clay, Duval (PDF), last updated 08/24/2021
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2022 Summary of Benefits - Hillsborough, Polk (PDF), last updated 08/24/2021
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2022 Summary of Benefits - Charlotte, Collier, Hernando, Lee, Manatee, Pasco, Pinellas, Sarasota (PDF), last updated 08/24/2021
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2022 Summary of Benefits - Lake, Marion, Sumter (PDF), last updated 08/24/2021
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2022 Summary of Benefits - Brevard, St. Lucie (PDF), last updated 08/24/2021
2022 Comprehensive Formulary
2022 Enrollment Form
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2022 Enrollment Form (PDF), last updated 07/30/2021
2022 Medicare Star Ratings
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2022 Medicare Star Rating (PDF), last updated 10/16/2021
2022 Prescription Drug Transition Policy
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2022 Prescription Drug Transition Policy (PDF), last updated 07/01/2021
2022 Low-Income Subsidy - Extra Help Program
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2022 Low-Income Subsidy - Medicare Extra Help Program (PDF), last updated 09/01/2021
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