Disenrollment Information

Medicare will only allow you to disenroll at certain times during the year. After we receive your disenrollment request, we will let you know if you can disenroll at that time. If you can, we will also confirm the effective date of your disenrollment.

Generally, you can disenroll from our plan and enroll in a new Medicare Prescription Drug Plan or Medicare Health Plan for the following year from October 15 through December 7. You may not enroll in a new plan during other times of the year unless you meet certain special exceptions, such as if you move out of our service area. If you qualify for Extra Help for your prescription drug costs you may enroll in or disenroll from a plan on a monthly basis at any time. If you lose this Extra Help during the year, your opportunity to change plans continues for two months after you are notified that you no longer qualify for Extra Help.

You may submit a disenrollment request in one of two ways:

1. Complete a Disenrollment Form / Spanish Disenrollment Form and send to:

Elixir Insurance
Attn: Enrollment/Disenrollment Dept
7835 Freedom Avenue NW
North Canton, OH 44720
Fax: 1-866-250-5178

2.Complete the Online Disenrollment Request.

Submitting your Disenrollment Request

You should not submit a disenrollment request if you are planning to enroll, or have enrolled, in another Medicare prescription drug plan or Medicare Advantage Prescription Drug plan. Enrolling in a prescription drug plan or a Medicare Advantage Prescription Drug plan will automatically disenroll you from Elixir Insurance. You should submit a disenrollment request only if you no longer want Medicare prescription drug coverage and want to disenroll from this coverage completely.

By disenrolling from Elixir Insurance, you are disenrolling from your Medicare prescription drug coverage. If you do not enroll in another Medicare Prescription Drug Plan (or a Medicare Advantage Plan with prescription drug coverage) at this time or you do not have or obtain creditable prescription drug coverage (as good as Medicare’s), you may have to pay a late enrollment penalty in addition to your premium for Medicare prescription drug coverage in the future. For information about the Medicare Plans available in your area, call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.

Information about your disenrollment request

Until your disenrollment date, you should keep using Elixir Insurance network pharmacies to fill your prescriptions. If you use an out-of-network pharmacy and there is not an emergency, Elixir Insurance may not pay for your prescriptions. After your disenrollment date, Elixir Insurance will not cover any prescription drugs you receive.

Can I be disenrolled involuntarily?

You may be involuntarily disenrolled from a Plan in special circumstances. These special circumstances include the following:

  • Change in Residence
  • Loss of Medicare Entitlement
  • Prescription Drug Plan (PDP) contract terminated or PDP discontinues or reduces service area so that an individual no longer resides in the plan service area.
  • Incarceration
  • Failure to pay premiums
  • Misrepresentation regarding coverage from member
  • Disruptive member behavior
  • Death

We cannot ask you to leave our plan because of your health.

If you have any questions about disenrollment procedures, please call Member Services at 1-866-250-2005, 24 hours a day, 7 days a week (TTY users should call 711).

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