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Plan forms

Forms to change or disenroll from your plan, request a reimbursement, or enroll in an electronic funds transfer.

Change Forms

Use a Change Form to move from one plan to another plan. For example, you can use a Change Form to move from Keystone 65 Preferred Rx HMO to Keystone 65 Select Rx HMO or Personal Choice 65 Medical-Only PPO to Personal Choice 65 Rx PPO. This change can only occur during a valid Election Period.

Please keep in mind that you cannot use a change form to switch between Personal Choice 65 PPO, a Blue Cross Medicare Advantage PPO Plan from QCC Insurance Company to Keystone 65 HMO, a Blue Cross Medicare Advantage HMO Plan from Keystone Health Plan East.

Keystone 65 HMO

Mail to:
Keystone 65 HMO
PO Box 7799
Philadelphia PA 19101-7799

Personal Choice 65 PPO

Mail to:
Personal Choice 65 PPO
PO Box 7799
Philadelphia PA 19101-7799

Claim reimbursement forms

Influenza claim

As a member of Keystone 65 HMO or Personal Choice 65SM PPO, you are covered for an influenza vaccine each year. If you received your vaccine at a non-participating provider and paid out of pocket, you can use the following forms to apply for reimbursement.

Out-of-network claim

To request a reimbursement as a Personal Choice 65 PPO Member for a out-of-network claim, please complete the non-network claim form and submit to the Independence Blue Cross Claims Department at the address listed on the form.

Cataract glasses claim

Reimbursement claims for post-surgery cataract glasses and lenses for Independence Medicare Advantage members must be submitted by the provider. For questions regarding this matter, please contact Provider Services at 1-800-275-2583 (TTY 711) Monday to Friday, 8 a.m. to 6 p.m.

Disenrollment instructions

If you want to leave your current Medicare Advantage plan or switch plans, review the information below.

Important: You can only make changes during certain times of the year unless you qualify for a special enrollment period.

Do I need a disenrollment form?

Fill out a disenrollment form if:

  • You want to return to Original Medicare only and do not want Medicare drug coverage (Part D).

Do NOT fill out a disenrollment form if:

  • You are joining another Medicare Advantage plan. Your new plan enrollment will automatically remove you from your current plan.
  • You are enrolling in a Medicare prescription drug plan (Part D). Enrolling in a Part D plan will automatically remove you from your Medicare Advantage plan and return you to Original Medicare.

When can I make changes to my Medicare coverage?

Annual Enrollment Period (AEP) — October 15 through December 7

During this time, you can:

  • Join a Medicare Advantage plan
  • Switch to a different Medicare Advantage plan
  • Add or remove prescription drug coverage
  • Return to Original Medicare

Your new coverage starts January 1.

Open Enrollment Period (OEP) — January 1 through March 31

If you are already enrolled in a Medicare Advantage plan (except a Medicare Medical Savings Account plan), you can:

  • Switch to another Medicare Advantage plan, or
  • Leave your Medicare Advantage plan and return to Original Medicare

Your change becomes effective on the first day of the month after your request is received.

For example:

Request received Coverage change effective

January
February
March

February 1
March 1
April 1

Note: During OEP, people with Original Medicare cannot join a Medicare Advantage plan. Most people with Original Medicare also cannot change their standalone Part D plan during this period.

Special exceptions

You may be able to make changes at other times of the year if you qualify for a Special Enrollment Period.

Examples include:

  • Moving outside your plan's service area
  • Joining a 5-star Medicare plan
  • Qualifying for Extra Help with prescription drug costs

If you qualify for Extra Help, you may be able to join or leave a plan at any time. If you lose Extra Help, you may still have up to two months to make a plan change.

Extra help in paying for your insurance plan

People with limited income may qualify for Extra Help, a Medicare program that can lower prescription drug costs.

Extra Help may reduce or eliminate:

  • Monthly plan premiums
  • Deductibles
  • Copays and coinsurance
  • Late enrollment penalties

Many people who qualify don't realize they are eligible.

Learn more:

You can also learn more about other money saving programs.

Before you leave the plan

Keep using your current plan's doctors and network providers until your disenrollment is effective.

To avoid unexpected costs, contact us to confirm your disenrollment date before receiving care outside the plan's network.

How do I submit the disenrollment request?

If you want to return to Original Medicare and are eligible to make a change, complete the appropriate disenrollment form and send it to:

Independence Blue Cross
Medicare Department
P.O. Box 7330
Philadelphia, PA 19101-8957

You can also fax your signed and dated form to 1-215-241-2275.

Need help?

For help understanding your Medicare options, call 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week.

2027 Keystone 65 HMO disenrollment forms

2027 Personal Choice 65 PPO disenrollment forms

2026 Keystone 65 HMO disenrollment forms

2026 Personal Choice 65 PPO disenrollment forms

 

What are my Medigap rights?

If you are returning to Original Medicare, you may have a special right to buy a Medigap (Medicare Supplement) plan, even if you have certain health conditions.

You may qualify if you:

  • Are age 65 or older and enrolled in Medicare Part B within the last 6 months
  • Are moving out of your current plan's service area
  • Meet other qualifying situations under Medicare rules

These special protections are required by federal law. Your state may offer additional Medigap protections.

Need help understanding your Medigap rights?

For questions about Medigap plans or your rights in Pennsylvania, contact PA MEDI (Pennsylvania Medicare Education and Decision Insight) at 1-800-783-7067

You can also contact Medicare at 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048

Available 24 hours a day, 7 days a week. If you need additional assistance, please contact the Member Help Team.

Cancel your Medicare Supplement (Medigap) plan

Use the disenrollment form if you would like to cancel your:

  • Security 65 plan, or
  • MedigapSecurity plan

Once you complete and sign the form, send it to us by mail or fax.

Mail your form

Independence Blue Cross
Medicare Department
P.O. Box 13713
Philadelphia, PA 19101-3713

Fax your form to 1-215-238-2289.

Before you submit

  • Complete all required fields
  • Sign and date the form
  • Keep a copy for your records

Cancellation Request Forms (without Estate)

Cancellation Request Forms (with Estate)

Independence Blue Cross Electronic Funds Transfer (EFT) form

 

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Website last updated: 8/4/2026