HMSA’s 65C Plus (Cost) Change Form
This form is for current 65C Plus (Cost) members who want to switch health plan
and/or Prescription Drug Coverage options. You must print and fill out this change
form. Mail your completed form to HMSA at the address on the bottom of this page. You may also fax your completed application to (808) 948-6343 (on Oahu).
Completed change forms requesting health plan option changes must be received by
the last business day of a month to be approved for the first day of the next month.
For example, change forms received by Jan. 31, 2013, will have a proposed effective
date of Feb. 1, 2013, subject to Centers for Medicare and Medicaid Services (CMS) approval.
Enrollment changes in HMSA’s 65C Plus Prescription Drug Coverage are
possible only at certain times during the year. In general, enrollment or changes
to HMSA’s 65C Plus Prescription Drug Coverage are allowed only during the
Annual Election Period, Oct. 15 – Dec. 7, 2012, for an effective date of Jan. 1,
2013, unless you qualify
for a special election period. Enrollments are subject to approval from CMS. Contact our representatives at the phone numbers
listed in Contact Information for more
Note: If you have coverage through a group-sponsored arrangement, please contact
your benefits administrator before making any changes.
All four sections of this change form must be completed or your enrollment change
could be delayed.
- Your current HMSA member number(s) (65C Plus health plan subscriber number
and, if different from your health plan subscriber number, your 65C Plus Prescription
Drug Coverage subscriber number).
- Your primary care physician's name (optional)
- Write your name, residence address, mailing address (if different), birth date, sex (gender), current HMSA member number (or Medicare claim number), daytime telephone
number, and email address (optional).
- Write the name of your primary care provider.
- Indicate the change you want to make by checking off your current 65C
Plus option and what 65C Plus option you would like to change to.
- Check the box to request infromation in large-print format.
- Please read this important information.
- Indicate the payment option you want.
- Please this important information and sign and date the form.
- If the applicant is unable to sign, the applicant's legal representative must sign
and fill in their name, mailing address, telephone number, and indicate their relationship
to the applicant.
Mail change forms to:
HMSA / 6AMS-IP
P.O. Box 860
Honolulu, HI 96808-0860
Do not send payment with your change form. Once your enrollment
change is approved, we’ll send you a billing statement every month showing
you the premium you owe and the due date. You must pay your monthly premium in advance.
If you indicated on the change form that you want your premium withheld from your
Social Security Administration (SSA) or Railroad Retirement Board (RRB) check, we will contact you.
Important: If we do not receive your premiums on a timely basis
and reasonable attempts have been made to collect them, your membership in the 65C
Plus health plan and prescription drug coverage, if applicable, will be terminated.