DISENROLLMENT REQUEST

Disenrollment from EnvisionRxPlus 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 EnvisionRxPlus.

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