Medicare Forms
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BlueMedicare Premier (HMO)
2023 Service Area
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H1035-022 - Palm Beach
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H1035-023 - Hillsborough, Polk
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H1035-024 - Miami-Dade
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H1035-025 - Broward
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H1035-026 - Orange, Osceola, Seminole
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H1035-033 - Clay, Duval
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H1035-034 - Hernando, Pasco, Pinellas
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H1035-043 - Lake, Marion, Sumter
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H1035-045 - Charlotte, Collier, Lee, Manatee, Sarasota
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H1035-048 - Brevard, St. Lucie
BlueMedicare Premier (HMO)
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 - Palm Beach, last updated 9/19/2022
- 2023 Annual Notice of Changes - Hillsborough, Polk, last updated 9/19/2022
- 2023 Annual Notice of Changes - Miami-Dade, last updated 9/19/2022
- 2023 Annual Notice of Changes - Broward, last updated 9/19/2022
- 2023 Annual Notice of Changes - Orange, Osceola, Seminole, last updated 9/19/2022
- 2023 Annual Notice of Changes - Clay, Duval, last updated 9/19/2022
- 2023 Annual Notice of Changes - Hernando, Pasco, Pinellas, last updated 9/19/2022
- 2023 Annual Notice of Changes - Charlotte, Collier, Lee, Manatee, Sarasota, last updated 9/19/2022
- 2023 Annual Notice of Changes - Lake, Marion, Sumter, last updated 9/19/2022
- 2023 Annual Notice of Changes - Brevard, St. Lucie, last updated 9/19/2022
2023 Evidence of Coverage
- 2023 Evidence of Coverage - Palm Beach, last updated 9/20/2022
- 2023 Evidence of Coverage - Hillsborough, Polk, last updated 9/20/2022
- 2023 Evidence of Coverage - Miami-Dade, last updated 9/20/2022
- 2023 Evidence of Coverage - Broward, last updated 9/20/2022
- 2023 Evidence of Coverage - Orange, Osceola, Seminole, last updated 9/20/2022
- 2023 Evidence of Coverage - Clay, Duval, last updated 9/20/2022
- 2023 Evidence of Coverage - Hernando, Pasco, Pinellas, last updated 9/20/2022
- 2023 Evidence of Coverage - Charlotte, Collier, Lee, Manatee, Sarasota, last updated 9/20/2022
- 2023 Evidence of Coverage - Lake, Marion, Sumter, last updated 9/20/2022
- 2023 Evidence of Coverage - Brevard, St. Lucie, last updated 9/20/2022
2023 Summary of Benefits
- 2023 Summary of Benefits - Miami-Dade, last updated 8/23/2022
- 2023 Summary of Benefits - Palm Beach, last updated 8/23/2022
- 2023 Summary of Benefits - Orange, Osceola, Seminole, last updated 8/23/2022
- 2023 Summary of Benefits - Broward, last updated 8/23/2022
- 2023 Summary of Benefits - Clay, Duval, last updated 8/23/2022
- 2023 Summary of Benefits - Hillsborough, Polk, last updated 8/23/2022
- 2023 Summary of Benefits - Hernando, Pasco, Pinellas, last updated 8/23/2022
- 2023 Summary of Benefits - Charlotte, Collier, Lee, Manatee, Sarasota, last updated 8/23/2022
- 2023 Summary of Benefits - Lake, Marion, Sumter, last updated 8/23/2022
- 2023 Summary of Benefits - Brevard, St. Lucie, last updated 8/23/2022
2023 Comprehensive Formulary
- 2023 Comprehensive Formulary, last updated 01/15/2023
2023 Enrollment Form
- 2023 Enrollment Form, last updated 8/5/2022
2023 Medicare Star Rating
- 2023 Medicare Star Rating, last updated 10/12/2022
2023 Prescription Drug Transition Policy
- 2023 Prescription Drug Transition Policy, last updated 7/1/2022
2023 Low-Income Subsidy - Extra Help Program
- 2023 Low-Income Subsidy - Extra Help Program, last updated 9/23/2022
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