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View and download important forms and documents about your BlueMedicare plan from Florida Blue.

2022 Summary of Benefits

Summary of Benefits - Broward, Miami-Dade, Palm Beach (PDF), last updated 08/23/2021

Summary of Benefits - Hillsborough, Orange, Osceola, Pinellas, Polk (PDF), last updated 08/23/2021

 

2022 Evidence of Coverage

Evidence of Coverage - Broward, Palm Beach (PDF), last updated 08/28/2021

Evidence of Coverage - Hillsborough, Pinellas, Polk (PDF), last updated 08/28/2021

Evidence of Coverage - Orange, Osceola (PDF), last updated 08/28/2021

Evidence of Coverage - Miami-Dade (PDF), last updated 08/28/2021

 

2022 Annual Notice of Change

Annual Notice of Change - Broward, Palm Beach (PDF), last updated 08/25/2021

Annual Notice of Change - Hillsborough, Pinellas, Polk (PDF), last updated 08/25/2021

Annual Notice of Change - Orange, Osceola (PDF), last updated 08/25/2021

Annual Notice of Change - Miami-Dade (PDF), last updated 08/25/2021

 

2022 Comprehensive Formulary

Comprehensive Formulary - Miami-Dade (PDF), last updated 05/15/2022

Comprehensive Formulary - Broward, Hillsborough, Orange, Osceola, Palm Beach, Pinellas, Polk (PDF), last updated 05/15/2022

 

2022 Other Information & Documents

Enrollment Form (PDF), last updated 07/30/2021

Medicare Star Rating (PDF), last updated 10/16/2021

Prescription Drug Transition Policy (PDF), last updated 07/01/2021

Low-Income Subsidy - Medicare Extra Help Program (PDF), last updated 09/01/2021

Service Area Map (PDF), last updated 10/01/2021

FBM FORM H1035
Last Updated: 10.01.2021
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