Do you want to disenroll from your HMSA Medicare Advantage plan? Please print out this form, complete it, and mail it to HMSA at the address on the bottom of this page.

In general, enrollment or changes are allowed only during the annual election period from Oct. 15 to Dec. 7.

In certain situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get Extra Help paying for their drugs, those who have or are leaving an employer plan, and those who move out of the service area may be allowed to make a change at other times of the year.

If you enrolled in a Medicare Advantage plan effective Jan. 1 and don’t like your plan choice, you can switch to another Medicare health plan (either with or without Medicare prescription drug benefits) or switch to Original Medicare (either with or without Medicare prescription drug benefits) between Jan. 1 and March 31.

Note: If you have a group-sponsored health plan, please contact your benefits administrator before making any changes.

Please complete the entire form so we can process it for you without any delays.

• Write your:
  • Name
  • HMSA subscriber number
  • Telephone number
  • Birth date
  • Gender
• Sign and date the form.
• Fill out the second page and check the box next to the statement that applies to you.

Mail disenrollment requests to:

HMSA – Membership Services
P.O. Box 860
Honolulu, HI  96808