Medicare Member Disenrollment Form

Are you a Wellcare or Wellcare by ‘Ohana member who would like to disenroll from your Medicare Advantage plan? Use this form to request a disenrollment. If you request disenrollment, you must continue to get all medical care from your plan until the effective date of disenrollment. Contact Us to verify your disenrollment before you seek medical services outside of our network. We will notify you of your effective date following receipt of this form.

Note: To complete this form, you must have a valid disenrollment password. To obtain a disenrollment password, please Contact Us. One of our helpful Member Services representatives will speak with you about disenrollment and provide you with your password.

Fields marked with * are REQUIRED.

Member First Name*

Member Last Name*

Member ID*

Address (Line 1)*

Address (Line 2)

City*

State*

ZIP Code*

Phone Number*

Typically, you may disenroll from a Medicare Advantage plan only during the Annual Enrollment Period from October 15 through December 7 of each year or during the Medicare Advantage Open Enrollment Period from January 1 through March 31 of each year. There are exceptions that may allow you to disenroll from a Medicare Advantage plan outside of this period.

Please read the following statements carefully, and select if the statement applies to you. By selecting one of the following, you are certifying that, to the best of your knowledge, you are eligible for an Election Period.

Special Election Period Reason*:

I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance or lost Medicaid).

I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help or lost Extra Help).

I have both Medicare and Medicaid (or my State helps pay for my Medicare premiums) or I get Extra Help paying for Medicare prescription drug coverage, but I haven’t had a change.

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long-term care facility).

I am joining a PACE program.

I am joining employer or union coverage.

I was enrolled in a plan by Medicare (or my state), and I want to choose a different plan.

When did the change take place or is taking place?*

Disenrollment Call Password*
(Don’t have this? Contact Us)

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Medicare Member Disenrollment Form

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Medicare Member Disenrollment Form

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