Automatic payments are available at no cost to HMSA Medicare Advantage plan members. Most of Hawaii’s major banks, savings and loans, and some credit unions participate with HMSA’s automatic premium payment plan.

To apply for the premium payment service, please print and fill out this form. Mail it to HMSA at the address below.

To avoid delays, please make sure your information is complete.

• Fill in your name, address, telephone number, and HMSA subscriber number.
• Print the name of your bank or financial institution and the branch you use. Designate a savings or checking account for your monthly deductions and fill in your account number and account holder names.
• Attach a voided check or a copy of your savings account statement (with account holder’s name and account information).
• Sign and date the form. HMSA member/ subscriber must also sign if different from account holder.

Mail all materials to:
HMSA
Attn: Cashiers
P.O. Box 4720
Honolulu, HI 96812-4720

The process takes about 30 days. Pay your premiums your usual way until you receive a confirmation notice from HMSA. At that time, your bank statement will begin showing a deduction for your HMSA premiums.

Questions? Please call us.
Oahu – 808-948-5555
Neighbor Islands – 1-800-620-4672 (toll-free)

Notes:

If your spouse or dependents are enrolled in separate individual plans, please complete a form for each HMSA subscriber account.

If you change your health plan or bank account, please complete a new authorization form.

To cancel your automatic premium deduction, send us a written request.