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 Value PPO

H5434 023 Pinellas
H5434 024 Highlands, Manatee, Sarasota
H5434 025 Bay, Calhoun, Escambia, Franklin, Gadsden, Jefferson, Leon, Liberty, Okaloosa, Santa Rosa, Wakulla, Walton
H5434 026 Broward, Indian River, Martin, Palm Beach, St. Lucie
H5434 030 Charlotte, Lee
H5434 031 Clay, Duval, Nassau, St. Johns, Brevard, Flagler, Volusia
H5434 034 Polk, Hillsborough
H5434 035 Citrus, Hernando
H5434 036 Lake, Sumter, Marion

Annual Notice of Changes -- Pinellas - last updated 8/26/25
Annual Notice of Changes -- Highlands, Manatee, Sarasota - last updated 8/26/25
Annual Notice of Changes -- Bay, Calhoun, Escambia, Franklin, Gadsden, Jefferson, Leon, Liberty, Okaloosa, Santa Rosa, Wakulla, Walton - last updated 8/26/25
Annual Notice of Changes -- Broward, Indian River, Martin, Palm Beach, St. Lucie - last updated 8/26/25
Annual Notice of Changes -- Charlotte and Lee - last updated 8/26/25
Annual Notice of Changes -- Brevard, Clay, Duval, Flagler, Nassau, St. Johns, Volusia - last updated 8/26/25
Annual Notice of Changes -- Hillsborough, Polk - last updated 8/26/25
Annual Notice of Changes -- Citrus, Hernando - last updated 8/26/25
Annual Notice of Changes -- Lake, Marion, Sumter - last updated 8/26/25

Evidence of Coverage -- Pinellas - last updated 9/4/25
Evidence of Coverage -- Highlands, Manatee, Sarasota - last updated 9/4/25
Evidence of Coverage -- Bay, Calhoun, Escambia, Franklin, Gadsden, Jefferson, Leon, Liberty, Okaloosa, Santa Rosa, Wakulla, Walton - last updated 9/4/25
Evidence of Coverage -- Broward, Indian River, Martin, Palm Beach, St. Lucie - last updated 9/4/25
Evidence of Coverage -- Charlotte, Lee - last updated 9/4/25
Evidence of Coverage -- Brevard, Clay, Duval, Flagler, Nassau, St. Johns, Volusia - last updated 9/4/25
Evidence of Coverage -- Hillsborough, Polk - last updated 9/4/25
Evidence of Coverage -- Citrus, Hernando - last updated 9/4/25
Evidence of Coverage -- Lake, Marion, Sumter - last updated 9/4/25

Summary of Benefits -- Pinellas, Hillsborough, Polk - last updated 9/4/25
Summary of Benefits -- Highlands, Manatee, Sarasota, Charlotte, Lee - last updated 9/4/25
Summary of Benefits -- Bay, Calhoun, Escambia, Franklin, Gadsden, Jefferson, Leon, Liberty, Okaloosa, Santa Rosa, Wakulla, Walton - last updated 9/4/25
Summary of Benefits -- Broward, Indian River, Martin, Palm Beach, St. Lucie - last updated 9/4/25
Summary of Benefits -- Brevard, Clay, Duval, Flagler, Nassau, St. Johns, Volusia - last updated 9/4/25
Summary of Benefits -- Citrus, Hernando - last updated 9/4/25
Summary of Benefits -- Lake, Marion, Sumter - last updated 9/4/25

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

Formulary -- Statewide - last updated 10/7/25

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 5/28/25

2025 BlueMedicare Value (PPO)

• H5434-023 - BlueMedicare Value (PPO) - Pinellas
• H5434-024 - BlueMedicare Value (PPO) - Highlands, Manatee, Sarasota
• H5434-025 - BlueMedicare Value (PPO) - Bay, Calhoun, Escambia, Franklin, Gadsden, Jefferson, Leon, Liberty, Okaloosa, Santa Rosa, Wakulla, Walton
• H5434-026 - BlueMedicare Value (PPO) - Broward, Indian River, Martin, Palm Beach, St. Lucie
• H5434-030 - BlueMedicare Value (PPO) - Charlotte, Lee
• H5434-031 - BlueMedicare Value (PPO) - Clay, Duval, Nassau, St. Johns, Flagler, Volusia, Brevard
• H5434-034 - BlueMedicare Value (PPO) - Polk, Hillsborough
• H5434-035 - BlueMedicare Value (PPO) - Citrus, Hernando
• H5434-036 - BlueMedicare Value (PPO) - Lake, Sumter, Marion