[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-detail-167037-en":3,"doc-seo-167037-105":29,"detail-sidebar-cat-1-en-105":94},{"code":4,"msg":5,"data":6},0,"success",{"doc_id":7,"user_id":8,"nickname":9,"user_avatar":10,"doc_module":11,"category_id":12,"category_name":13,"doc_title":14,"doc_description":15,"doc_content":16,"file_id":17,"file_url":18,"file_type":19,"file_size":20,"view_count":4,"is_deleted":4,"is_public":11,"is_downloadable":11,"audit_status":11,"page_count":21,"language":22,"language_code":23,"site_id":24,"html_lang":23,"table_of_contents":25,"faqs":26,"seo_title":27,"seo_description":15,"update_tm":28,"read_time":11},167037,687207017582,"Ethan Miller","https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d",1,17,"Forms","Disenrollment Form - Disenrollment Instructions and Member Information","Disenrollment Form for Group MedicareBlue Rx includes instructions for members who want to disenroll from the Group MedicareBlue SM Rx (PDP) plan. The form explains notification steps to the benefits administrator, employer group or union contact, where to mail the completed request, and key contact numbers for general disenrollment questions and plan information. It also collects member details, requested disenrollment date, and required signatures, including authorization by a representative when applicable.","Group MedicareBlue Rx\nP.O. Box 3178 Scranton, PA 18505\nYourMedicareSolutions.com\nDisenrollment Form\nDisenrollment Instructions:\nIf you wish to disenroll from Group MedicareBlue SM Rx (PDP), please carefully read and complete all sections on this form. Notify your benefits administrator, employer group or union contact of your intent to disenroll before signing and dating the form. Mail completed form to Group MedicareBlue Rx at P.O. Box 3178, Scranton, PA 18505. For information about disenrolling, call 1-877-838-3827 8:00 a.m. to 8:00 p.m., daily, Central and Mountain Times. TTY users should call 711. For information about plans in your area, call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week.\nTTY users should call 1-877-486-2048.\nMember Information (Please print your name and address below):\nGroup Name: \tGroup Number:  \t Name:\t\t\t Street Address:\nCity:\n\u000eState:\n\u000eZip:\nCounty:\t\t\t Date of Birth:  \t Group MedicareBlue Rx ID #\n\u000eHome Phone:\nMedicare Number:\nBy completing this disenrollment request, I agree to the following:\nGroup MedicareBlue Rx will notify me of my disenrollment date after they get this form. I understand that until my disenrollment is effective, I must continue to fill my prescriptions at Group MedicareBlue Rx network pharmacies to get coverage. I understand that there are limited times in which I will be able to join other Medicare plans, unless I qualify for certain special circumstances.\nI understand that I am 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 for this coverage in the future.\nRequested disenrollment date:\nMember Signature *: \tDate:\n* Or the signature of the person authorized to act on behalf of the individual under the laws of the State where the individual resides. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this disenrollment and 2) documentation of this authority is available upon request by Group MedicareBlue Rx or by Medicare.\nS5743_081618GKK01_C\nIf you are the authorized representative, you must provide the following information:\nAuthorized Representative Signature*: \t\tDate:\t\t Authorized Representative Name (Print): \tPhone No.:  \t Authorized Representative Address:  \t\t\t\t Relationship to Member\nGroup MedicareBlueSM Rx (PDP) is a Medicare-approved Part D sponsor. Enrollment in Group MedicareBlue Rx depends on renewal of the plan sponsor's contract with Medicare.\nCoverage is available to members of an employer or union group and separately issued by one of the following plans: Wellmark Blue Cross and Blue Shield of Iowa*; Blue Cross and Blue Shield of Minnesota*; Blue Cross and Blue Shield of Montana*, a division of Health Care Service Corporation, a Mutual Legal Reserve Company; Blue Cross and Blue Shield of Nebraska*; Blue Cross Blue Shield of North Dakota*; Wellmark Blue Cross and Blue Shield of South Dakota*; and Blue Cross Blue Shield of Wyoming*.\n*Independent licensees of the Blue Cross and Blue Shield Association.","cbCaitzlP7UbxAb5","https://ap.wps.com/l/cbCaitzlP7UbxAb5","docx",181895,2,"English","en",105,"# Disenrollment Instructions\n# Member Information\n## Member Agreement Statements\n## Requested Disenrollment Date and Signatures\n# Authorized Representative Information\n# Additional Plan Notes","[{\"question\":\"How does a member submit a disenrollment request for Group MedicareBlue SM Rx (PDP)?\",\"answer\":\"Complete all sections on the disenrollment form, notify the benefits administrator, employer group or union contact of the intent to disenroll before signing and dating, and mail the completed form to Group MedicareBlue Rx at P.O. Box 3178, Scranton, PA 18505.\"},{\"question\":\"What must members continue doing until the disenrollment becomes effective?\",\"answer\":\"Members must continue filling prescriptions at Group MedicareBlue Rx network pharmacies until their disenrollment is effective to maintain coverage.\"},{\"question\":\"What happens if the member disenrolls from a Medicare Prescription Drug Plan without good alternative coverage?\",\"answer\":\"The member may have to pay a late enrollment penalty for future coverage if they do not have other coverage as good as Medicare.\"},{\"question\":\"If someone signs for the member as an authorized representative, what additional information is required?\",\"answer\":\"The authorized representative must provide their signature, date, name, phone number, address, and relationship to the member, and the signature certifies authorization under the state’s laws.\"}]","Disenrollment Form - Disenrollment Instructions and Member Information | DOCX",1788206853,{"code":4,"msg":30,"data":31},"ok",{"site_id":24,"language":23,"slug":32,"title":14,"keywords":33,"description":15,"schema_data":34,"social_meta":89,"head_meta":91,"extra_data":93,"updated_unix":28},"disenrollment-form-disenrollment-instructions-and-member-information","",{"@graph":35,"@context":88},[36,52,67],{"@type":37,"itemListElement":38},"BreadcrumbList",[39,43,46,49],{"item":40,"name":41,"@type":42,"position":11},"https://docshare.wps.com","Home","ListItem",{"item":44,"name":45,"@type":42,"position":21},"https://docshare.wps.com/template/","Template",{"item":47,"name":13,"@type":42,"position":48},"https://docshare.wps.com/template/forms/",3,{"item":50,"name":14,"@type":42,"position":51},"https://docshare.wps.com/template/disenrollment-form-disenrollment-instructions-and-member-information/167037/",4,{"url":50,"name":14,"@type":53,"author":54,"headline":14,"publisher":56,"fileFormat":59,"inLanguage":23,"description":15,"dateModified":60,"datePublished":61,"encodingFormat":59,"isAccessibleForFree":62,"interactionStatistic":63},"DigitalDocument",{"name":9,"@type":55},"Person",{"url":40,"name":57,"@type":58},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-09-01","2026-08-31",true,{"@type":64,"interactionType":65,"userInteractionCount":11},"InteractionCounter",{"@type":66},"ViewAction",{"@type":68,"mainEntity":69},"FAQPage",[70,76,80,84],{"name":71,"@type":72,"acceptedAnswer":73},"How does a member submit a disenrollment request for Group MedicareBlue SM Rx (PDP)?","Question",{"text":74,"@type":75},"Complete all sections on the disenrollment form, notify the benefits administrator, employer group or union contact of the intent to disenroll before signing and dating, and mail the completed form to Group MedicareBlue Rx at P.O. Box 3178, Scranton, PA 18505.","Answer",{"name":77,"@type":72,"acceptedAnswer":78},"What must members continue doing until the disenrollment becomes effective?",{"text":79,"@type":75},"Members must continue filling prescriptions at Group MedicareBlue Rx network pharmacies until their disenrollment is effective to maintain coverage.",{"name":81,"@type":72,"acceptedAnswer":82},"What happens if the member disenrolls from a Medicare Prescription Drug Plan without good alternative coverage?",{"text":83,"@type":75},"The member may have to pay a late enrollment penalty for future coverage if they do not have other coverage as good as Medicare.",{"name":85,"@type":72,"acceptedAnswer":86},"If someone signs for the member as an authorized representative, what additional information is required?",{"text":87,"@type":75},"The authorized representative must provide their signature, date, name, phone number, address, and relationship to the member, and the signature certifies authorization under the state’s laws.","https://schema.org",{"og:url":50,"og:type":90,"og:title":14,"og:site_name":57,"og:description":15},"article",{"robots":92,"canonical":50},"index,follow",{"doc_id":7,"site_id":24},{"code":4,"msg":5,"data":95},[96,101,106,111,116,121,124,129,134],{"id":97,"doc_module":11,"doc_module_name":45,"category_name":98,"show_sort_weight":99,"slug":100},11,"Presentations",90,"presentations",{"id":102,"doc_module":11,"doc_module_name":45,"category_name":103,"show_sort_weight":104,"slug":105},12,"Resumes",80,"resumes",{"id":107,"doc_module":11,"doc_module_name":45,"category_name":108,"show_sort_weight":109,"slug":110},14,"Invoices",70,"invoices",{"id":112,"doc_module":11,"doc_module_name":45,"category_name":113,"show_sort_weight":114,"slug":115},15,"Posters",60,"posters",{"id":117,"doc_module":11,"doc_module_name":45,"category_name":118,"show_sort_weight":119,"slug":120},16,"Social Media",50,"social-media",{"id":12,"doc_module":11,"doc_module_name":45,"category_name":13,"show_sort_weight":122,"slug":123},40,"forms",{"id":125,"doc_module":11,"doc_module_name":45,"category_name":126,"show_sort_weight":127,"slug":128},18,"Letters",30,"letters",{"id":130,"doc_module":11,"doc_module_name":45,"category_name":131,"show_sort_weight":132,"slug":133},21,"Paper Templates",5,"papers-templates",{"id":135,"doc_module":11,"doc_module_name":45,"category_name":136,"show_sort_weight":4,"slug":137},158,"General","general-158"]