Disenrollment from Elixir Insurance means ending your membership with us. Medicare will only allow you to disenroll at certain times during the year. Generally, you may not enroll in a new Plan during a time outside the open enrollment request (October 15 through December 7) unless you meet certain special exceptions. For more information on when you can disenroll, please call Member Services at 1-866-250-2005, 24 hours a day, 7 days a week (TTY users should call 711).

By completing this disenrollment request, I agree to the following:

The plan will send me a letter with the date my plan coverage ends after they get this form. I understand that until the date my coverage ends, I must continue to fill my prescriptions at plan network pharmacies to get coverage for my prescription drugs, except in an emergency situation. I understand that there are limited times in which I’ll be able to join other Medicare plans, unless I qualify for an exception under certain special circumstances.

I understand that I’m disenrolling from my Medicare Prescription Drug plan and if I don’t have other coverage as good as Medicare, I may have to pay a Late Enrollment Penalty (LEP) for this coverage in the future. I understand that I’m responsible for any and all monthly payments while my Medicare Prescription Drug plan is active.

By submitting this information you are requesting to be disenrolled from Elixir Insurance.

Disenrollment Reason

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