Medicare Forms
Medicare Advantage (Part C)

2025 Plan Mapping 
•    H1035-017 - BlueMedicare Classic (HMO) - Miami-Dade
•    H1035-019 - BlueMedicare Classic (HMO) - Broward, Martin, St. Lucie, Bay, Citrus, Clay, Duval, Escambia, Marion, Okaloosa, Santa Rosa, St. Johns, Walton, Charlotte, Collier, Lee, Manatee, Sarasota, Brevard, Lake, Sumter
•    H1035-020 - BlueMedicare Classic (HMO) - Orange, Osceola, Seminole
•    H1035-021 - BlueMedicare Classic (HMO) - Hernando, Hillsborough, Pasco, Polk

•    2025 Annual Notice of Changes - BlueMedicare Classic (HMO) - Miami-Dade - last updated 8/23/24
•    2025 Annual Notice of Changes - BlueMedicare Classic (HMO) - Palm Beach - last updated 8/23/24
•    2025 Annual Notice of Changes - BlueMedicare Classic (HMO) - Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Lake, Lee, Manatee, Marion, Martin, Okaloosa, Santa Rosa, Sarasota, St. Johns, St. Lucie, Sumter - last updated 8/23/24
•    2025 Annual Notice of Changes - BlueMedicare Classic (HMO) - Orange, Osceola, Seminole - last updated 8/23/24
•    2025 Annual Notice of Changes - BlueMedicare Classic (HMO) - Hernando, Hillsborough, Pasco, Polk - last updated 8/23/24

•    2025 Evidence of Coverage - BlueMedicare Classic (HMO) - Miami-Dade - last updated 9/3/24
•    2025 Evidence of Coverage - BlueMedicare Classic (HMO) - Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Lake, Lee, Manatee, Marion, Martin, Okaloosa, Santa Rosa, Sarasota, St. Johns, St. Lucie, Sumter, Walton - last updated 9/3/24
•    2025 Evidence of Coverage - BlueMedicare Classic (HMO) - Orange, Osceola, Seminole - last updated 9/3/24
•    2025 Evidence of Coverage - BlueMedicare Classic (HMO) - Hernando, Hillsborough, Pasco, Polk - last updated 9/3/24

•    2025 Summary of Benefits - BlueMedicare Classic (HMO) - Miami-Dade - last updated 8/22/24
•    2025 Summary of Benefits - BlueMedicare Classic (HMO) - Bay, Citrus, Escambia, Martin, Okaloosa, Santa Rosa, St. Johns, Walton - last updated 8/22/24
•    2025 Summary of Benefits - BlueMedicare Classic (HMO) - Broward - last updated 8/22/24
•    2025 Summary of Benefits - BlueMedicare Classic (HMO) - Clay and Duval - last updated 8/22/24
•    2025 Summary of Benefits - BlueMedicare Classic (HMO) - Charlotte, Collier, Lee, Manatee, Sarasota - last updated 8/22/24
•    2025 Summary of Benefits - BlueMedicare Classic (HMO) - Brevard, St. Lucie - last updated 8/22/24
•    2025 Summary of Benefits - BlueMedicare Classic (HMO) - Orange, Osceola, Seminole - last updated 8/22/24
•    2025 Summary of Benefits - BlueMedicare Classic (HMO) - Hillsborough, Polk - last updated 8/22/24
•    2025 Summary of Benefits - BlueMedicare Classic (HMO) - Hernando, Pasco - last updated 8/22/24
•    2025 Summary of Benefits - BlueMedicare Classic (HMO) - Lake, Marion, Sumter - last updated 8/22/24

•    2025 Enrollment Form - BlueMedicare Classic (HMO) - last updated 7/12/24

•    2025 Medicare Star Rating - BlueMedicare Classic (HMO) - last updated 10/16/24

•    2025 Formulary - BlueMedicare Classic HMO - Miami Dade - last updated 12/20/2024

•    2025 Formulary - BlueMedicare Classic HMO - Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Hernando, Hillsborough, Lake, Lee, Manatee, Marion, Martin, Okaloosa, Orange, Osceola, Pasco, Polk, Santa Rosa, Sarasota, Seminole, St. Johns, St. Lucie, Sumter, Walton - last updated 12/20/2024

•    2025 Low Income Subsidy (LIS) - Extra Help Program - last updated 10/1/24

•    2025 Prescription Drug Transition Policy - last updated 8/14/24