Medicare Forms

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BlueMedicare Value (PPO)
2023 Service Area
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H5434-023 - Pinellas
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H5434-024 - Highlands, Manatee, Sarasota
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H5434-025 - Bay, Calhoun, Escambia, Franklin, Gadsden, Jefferson, Leon, Liberty, Okaloosa, Santa Rosa, Wakulla, Walton
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H5434-026 - Broward, Indian River, Martin, Palm Beach, St. Lucie
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H5434-030 - Charlotte, Collier, Lee
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H5434-031 - Clay, Duval, Nassau, St. Johns, Flagler, Volusia
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H5434-032 - Miami-Dade
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H5434-033 - Brevard, Orange, Osceola, Seminole
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H5434-034 - Polk, Hillsborough
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H5434-035 - Hernando, Pasco
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H5434-036 - Lake, Sumter, Marion
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H5434-039 - Alachua, Citrus
Important 2023 benefit information, last updated 2/14/2023
BlueMedicare Value (PPO)
2023 Plan Documents
View and download important forms and documents about your BlueMedicare plan from Florida Blue.
2023 Annual Notice of Changes
2023 Evidence of Coverage
2023 Summary of Benefits
Plan Document | Last Updated |
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2023 Summary of Benefits - Pinellas | last updated 9/12/2022 |
2023 Summary of Benefits - Hernando, Pasco | last updated 9/12/2022 |
2023 Summary of Benefits - Bay, Calhoun, Escambia, Franklin, Gadsden, Jefferson, Leon, Liberty, Okaloosa, Santa Rosa, Wakulla, Walton | last updated 9/12/2022 |
2023 Summary of Benefits - Clay, Duval, Flagler, Nassau, St. Johns, Volusia | last updated 9/12/2022 |
2023 Summary of Benefits - Broward, Indian River, Martin, Palm Beach, St. Lucie, Miami-Dade | last updated 9/12/2022 |
2023 Summary of Benefits - Highlands, Manatee, Sarasota, Charlotte, Collier, Lee | last updated 9/12/2022 |
2023 Summary of Benefits - Brevard, Orange, Osceola, Seminole | last updated 9/12/2022 |
2023 Summary of Benefits - Hillsborough, Polk | last updated 9/12/2022 |
2023 Summary of Benefits - Lake, Marion, Sumter | last updated 9/12/2022 |
2023 Summary of Benefits - Alachua, Citrus | last updated 9/12/2022 |
2023 Comprehensive Formulary
Plan Document | Last Updated |
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2023 Comprehensive Formulary | last updated 5/18/2023 |
2023 Enrollment Form
Plan Document | Last Updated |
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2023 Enrollment Form | last updated 8/11/2022 |
2023 Medicare Star Rating
Plan Document | Last Updated |
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2023 Medicare Star Rating | last updated 10/12/2022 |
2023 Prescription Drug Transition Policy
Plan Document | Last Updated |
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2023 Prescription Drug Transition Policy | last updated 7/1/2022 |
2023 Low-Income Subsidy - Extra Help Program
Plan Document | Last Updated |
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2023 Low-Income Subsidy - Extra Help Program | last updated 9/23/2022 |