Medicare Forms
2022 BlueMedicare Complete (HMO D-SNP)
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, St. Lucie (PDF), last updated 08/23/2021
Summary of Benefits - Brevard, Hillsborough, Lake, Orange, Osceola, Polk, Seminole, Sumter (PDF), last updated 08/23/2021
Summary of Benefits - Charlotte, Clay, Collier, Duval, Hernando, Lee, Manatee, Marion, Pasco, Pinellas, Sarasota (PDF), last updated 08/27/2021
2022 Evidence of Coverage
Evidence of Coverage - Miami-Dade (PDF), last updated 08/27/2021
Evidence of Coverage - Broward, Palm Beach, St Lucie (PDF), last updated 08/27/2021
Evidence of Coverage - Brevard, Lake, Orange, Osceola, Seminole, Sumter (PDF), last updated 08/27/2021
Evidence of Coverage - Hillsborough, Polk (PDF), last updated 08/27/2021
Evidence of Coverage - Clay, Duval, Marion (PDF), last updated 08/27/2021
Evidence of Coverage - Charlotte, Collier, Hernando, Lee, Manatee, Pasco, Pinellas, Sarasota (PDF), last updated 08/27/2021
2022 Annual Notice of Changes
Annual Notice of Changes - Miami-Dade (PDF), last updated 08/22/2021
Annual Notice of Changes - Broward, Palm Beach (PDF), last updated 08/22/2021
Annual Notice of Changes - Brevard, Orange, Osceola (PDF), last updated 08/22/2021
Annual Notice of Changes - Hillsborough, Polk (PDF), last updated 08/22/2021
Annual Notice of Changes - Clay, Duval, Marion (PDF), last updated 08/22/2021
Annual Notice of Changes - Collier, Hernando, Pasco, Pinellas (PDF), last updated 08/22/2021
2022 Comprehensive Formulary
2022 Other Information & Documents
Enrollment Form (PDF), last updated 08/24/2021
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