Medicare Forms
Medicare Advantage (Part C)

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

Call Member Services at 1-800-926-6565 (TTY 1-800-955-8770)

Hours: 8 a.m. to 8 p.m. local time, seven days a week, from October 1 through March 31, except for Thanksgiving and Christmas. From April 1 through September 30, our hours are 8 a.m. to 8 p.m. local time, Monday through Friday, except for major holidays.

2026 BlueMedicare Select PPO

H5434 002 Broward, Miami-Dade, Palm Beach, St. Lucie, Charlotte, Collier, Highlands, Hillsborough, Lee, Manatee, Pinellas, Orange, Osceola, Seminole, Bay, Duval, Escambia, Marion, Santa Rosa
H5434 045 Collier, Monroe, Okeechobee, DeSoto, Glades, Hardee, Hendry, Pasco, Alachua, Baker, Bradford, Columbia, Dixie, Gilchrist, Gulf, Hamilton, Holmes, Jackson, Lafayette, Levy, Madison, Putnam, Suwannee, Taylor, Union, Washington

Enrollment Form -- Statewide - last updated 8/13/25

Formulary -- Statewide - last updated 9/30/25

Medicare Star Rating -- Statewide - last updated 10/16/24

Low Income Subsidy (LIS) - Extra Help Program - last updated 8/29/25

Prescription Drug Transition Policy - last updated xx/xx/xx

2025 BlueMedicare Select (PPO)

• H5434-002 - BlueMedicare Select (PPO) - Broward, Palm Beach, St. Lucie, Miami-Dade, Charlotte, Collier, Highlands, Hillsborough, Lee, Manatee, Pinellas, Orange, Osceola, Seminole, Bay, Duval, Escambia, Marion, Santa Rosa
• H5434-045 - BlueMedicare Select (PPO) - Monroe, Okeechobee, Collier, DeSoto, Glades, Hardee, Hendry, Pasco, Alachua, Baker, Bradford, Columbia, Dixie, Gilchrist, Gulf, Hamilton, Holmes, Jackson, Lafayette, Levy, Madison, Putnam, Suwannee, Taylor, Union, Washington

• 2025 Annual Notice of Changes - BlueMedicare Select (PPO) - Bay, Broward, Charlotte, Collier, Duval, Escambia, Highlands, Hillsborough, Lee, Manatee, Marion, Orange, Osceola, Palm Beach, Pinellas, Santa Rosa, St. Lucie - last updated 9/12/24

• 2025 Evidence of Coverage - BlueMedicare Select (PPO) - Bay, Broward, Charlotte, Collier, Duval, Escambia, Highlands, Hillsborough, Lee, Manatee, Marion, Miami-Dade, Orange, Osceola, Palm Beach, Pinellas, Santa Rosa, Seminole, St. Lucie - last updated 5/28/25
• 2025 Evidence of Coverage - BlueMedicare Select (PPO) - Alachua, Baker, Bradford, Collier, Columbia, DeSoto, Dixie, Gilchrist, Glades, Gulf, Hamilton, Hardee, Hendry, Holmes, Jackson, Lafayette, Levy, Madison, Monroe, Okeechobee, Pasco, Putnam, Suwannee, Taylor, Union, Washington - last updated 5/28/25

•    2025 Summary of Benefits - BlueMedicare Select (PPO) - Bay, Broward, Charlotte, Duval, Escambia, Highlands, Hillsborough, Lee, Manatee, Marion, Miami-Dade, Palm Beach, Pinellas, Santa Rosa, St. Lucie - last updated 8/30/24
•    2025 Summary of Benefits - BlueMedicare Select (PPO) - Orange, Osceola, Seminole - last updated 8/30/24
•    2025 Summary of Benefits - BlueMedicare Select (PPO) - Baker, Bradford, Columbia, DeSoto, Dixie, Gilchrist, Glades, Gulf, Hamilton, Hardee, Hendry, Holmes, Jackson, Lafayette, Levy, Madison, Monroe, Okeechobee, Pasco, Putnam, Suwannee, Taylor, Union, Washington - last updated 8/30/24
•    2025 Summary of Benefits - BlueMedicare Select (PPO) - Alachua - last updated 8/30/24
•    2025 Summary of Benefits - BlueMedicare Select (PPO) - Collier - last updated 8/30/24