Form Instructions

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.

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. 29, 2010, will have a proposed effective date of Feb. 1, 2010, subject to CMS approval. Enrollment changes in HMSA’s 65C Plus Prescription Drug Coverage (Cost) are possible only at certain times during the year. In general, enrollment or changes to HMSA’s 65C Plus Prescription Drug Coverage (Cost) are allowed only during the Annual Election Period, Nov. 15 – Dec. 31, for an effective date of Jan. 1 of the following year, unless you qualify for a special election period. Contact our representatives at the phone numbers listed in Contact Information for more information.

All four sections of this change form must be completed or your enrollment change could be delayed.

You’ll need:

  • Your current HMSA member number(s) (65C Plus [Cost] health plan subscriber number and, if different from your health plan subscriber number, your 65C Plus Prescription Drug Coverage [Cost] subscriber number).

Section 1

  • Write your name and your current HMSA subscriber number(s) (65C Plus health [Cost] plan subscriber number and, if different from your health plan subscriber number, your 65C Plus Prescription Drug Coverage [Cost] subscriber number). Provide a daytime telephone number where we can contact you if we have any questions to avoid any delays in processing the form. Indicate the change you want to make by checking off both the health plan and (if applicable) Prescription Drug Coverage you want to be enrolled in.

Section 2

  • Please read this important information.

Section 3

  • Indicate the payment option you want.

Section 4

  • Read the agreement in section 5 before you or your legal guardian signs and dates the form.

Section 5

  • Read the agreement.

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 date by which we must receive it. 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), Railroad Retirement Board (RRB), or Office of Personnel Management (OPM) check, we will contact you about having your premium deducted from your SSA, RRB or OPM payment.

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.

This page is current as of Oct. 1, 2009. (H1251_4006_10_Web_Pages – CMS 1/8/2010)