June 2019 April 2019November 2018August 2018
General correspondence address:Premera Medicare Advantage PlansPO Box 262548Plano, TX 75026
Medicare Advantage Claim Reimbursement form
Medicare Advantage Automatic Funds Transfer Authorization
Ending your membership in our Plan may be voluntary (your own choice) or involuntary (not your own choice). You might leave our Plan because you have decided that you want to leave. There are also limited situations where we are required to end your membership (for example, if you move permanently out of our geographic service area).
There are only certain times during the year when you may voluntarily end your membership in our plan. The key time to make changes is the Medicare Fall Open Enrollment Period (also known as the Annual Election Period), which occurs from October 15 through December 7 for enrollments starting January 1 of the following year. This is the time to review your health care and drug coverage for the following year and make changes to your Medicare health or prescription drug coverage. Any changes you make during this time will begin January 1. Certain individuals, such as those with Medicaid, those who get extra help or who move, can make changes at other times. For more information on when you can make changes see the enrollment period table later in this section.
If you want to end your membership in our plan during this time, this is what you need to do:
If you leave our plan, it may take some time for your membership to end and your new Medicare plan to start. While you are waiting for your membership to end, you are still a member and must continue to get your care and prescription drugs as usual through our plan. If you happen to be hospitalized on the day your membership ends, generally you will be covered by our plan until you are discharged. Call customer service for more information and to help us coordinate with your new plan. Until your prescription drug coverage with our plan ends, use our network pharmacies to fill your prescriptions. While you are waiting for your membership to end, you are still a member and must continue to get your prescription drugs through our plan’s network pharmacies. In most cases, your prescriptions are covered only if they are filled at a network pharmacy, including our mail-order-pharmacy service, are listed on our formulary, and you follow other coverage rules.
We cannot ask you to leave your health plan for any health-related reasons. If you ever feel that you are being encouraged or asked to leave our plan because of your health, you should call 800-MEDICARE (800-633-4227), which is the national Medicare help line. TTY/TTD users should call 877-486-2048 (TTY/TDD: 711). You may call 24 hours a day, 7 days a week.
If any of the following situations occur, we will end your membership in our plan:
You have the right to make a complaint if we end your membership in our plan. We will tell you our reasons in writing and explain how you may file a complaint against us.
CMS Appointment of Representative Form
Medicare Complaint Form
To check on your status or level, call:
800-MEDICARE (800-633-4227), 24 hours per day, 7 days per week. TTY/TDD users should call 877-486-2048 (TTY/TDD: 711).