2018 HMSA Akamai Advantage Disenrollment Request Form

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Do you want to disenroll from your HMSA Akamai 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, October 15 – December 7, 2017. Your plan will start January 1, 2018. However, you could qualify for a special election period. If you don't qualify for a special election period and if you miss the annual election period, you must wait until October 15 – December 7, 2018. Your plan would start January 1, 2019. The Centers for Medicare & Medicaid Services (CMS) must approve your enrollment. Contact our representatives at the phone numbers listed in Contact Information for more information.

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
    • Medicare 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 change forms to:

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

If you have other health plan benefits, such as a retiree plan, Medicare Supplement Insurance (Medigap) policy, or an Affordable Care Act (ACA) plan, you may have to contact the plan directly to cancel it. Call us so we can help you determine if you need to cancel your other plan.