Medicare Forms
2022 BlueMedicare Patriot (PPO)
View and download important forms and documents about your BlueMedicare plan from Florida Blue.
2022 Summary of Benefits
Summary of Benefits - Hillsborough, Pasco, Pinellas (PDF), last updated 08/24/2021
Summary of Benefits - Bay, Escambia, Okaloosa, Santa Rosa, Walton (PDF), last updated 08/24/2021
Summary of Benefits - Clay, Duval, Nassau, St. Johns (PDF), last updated 08/24/2021
Summary of Benefits - Brevard, Orange (PDF), last updated 08/24/2021
Summary of Benefits - Lake, Marion, Sumter (PDF), last updated 08/24/2021
2022 Evidence of Coverage
Evidence of Coverage - Lake, Marion, Sumter (PDF), last updated 09/06/2021
Evidence of Coverage - Bay, Escambia, Okaloosa, Santa Rosa, Walton (PDF), last updated 09/06/2021
Evidence of Coverage - Clay, Duval, Nassau, St. Johns (PDF), last updated 09/06/2021
Evidence of Coverage - Hillsborough, Pasco, Pinellas (PDF), last updated 09/06/2021
Evidence of Coverage - Brevard, Orange (PDF), last updated 09/06/2021
2022 Annual Notice of Changes
Annual Notice of Changes - Lake, Marion, Sumter (PDF), last updated 08/25/2021
2022 Other Information & Documents
Enrollment Form (PDF), last updated 08/24/2021
Medicare Star Rating (PDF), last updated 10/16/2021
Service Area Map (PDF), last updated 10/012021