Medicare Forms
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BlueMedicare Saver (HMO)
2023 Service Area
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H1035-035 - Broward, Palm Beach
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H1035-037 - Hillsborough, Pinellas, Polk
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H1035-038 - Orange, Osceola
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H1035-039 - Miami-Dade
BlueMedicare Saver (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 - Broward, Palm Beach, last updated 9/19/2022
- 2023 Annual Notice of Changes - Hillsborough, Pinellas, Polk, last updated 9/19/2022
- 2023 Annual Notice of Changes - Orange, Osceola, last updated 9/19/2022
- 2023 Annual Notice of Changes - Miami-Dade, last updated 9/19/2022
2023 Evidence of Coverage
- 2023 Evidence of Coverage - Broward, Palm Beach, last updated 9/20/2022
- 2023 Evidence of Coverage - Hillsborough, Pinellas, Polk, last updated 9/20/2022
- 2023 Evidence of Coverage - Orange, Osceola, last updated 9/20/2022
- 2023 Evidence of Coverage - Miami-Dade, last updated 9/20/2022
2023 Summary of Benefits
- 2023 Summary of Benefits - Broward, Palm Beach, Miami-Dade, last updated 8/23/2022
- 2023 Summary of Benefits - Hillsborough, Pinellas, Polk, Orange, Osceola, last updated 8/23/2022
2023 Comprehensive Formulary
- 2023 Comprehensive Formulary - Miami-Dade, last updated 01/15/2023
- 2023 Comprehensive Formulary - Broward, Hillsborough, Orange, Osceola, Palm Beach, Pinellas, Polk, 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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