18008338554 2026

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The document is a disenrollment form for Blue MedicareRx Premier, detailing the process for members to officially disenroll from their Medicare Prescription Drug Plan. It provides instructions for submitting the form via mail or fax, outlines the implications of disenrollment, and includes sections for personal information and signatures. Additionally, it mentions the potential consequences of not having alternative coverage and provides information about Anthem Insurance Companies Inc. as the plan sponsor.

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Click ‘Get Form’ to open the disenrollment form in the editor.
Begin by entering your Last Name, First Name, and Middle Initial in the designated fields. Select your title (Mr., Mrs., Miss, Ms.) to personalize your request.
Input your Member ID and Birth Date accurately. Ensure that you select your Sex (Male or Female) from the options provided.
Fill in your Home Phone Number, including the area code, to ensure they can contact you if needed.
Read the agreement statement carefully. By completing this form, you acknowledge understanding of the disenrollment process and its implications.
Sign and date the form at the bottom. If someone is signing on your behalf, provide their information as required.
Once completed, save your document and choose to either mail it to the specified address or fax it using the provided number.

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What is Anthem Dual Advantage HMO D SNP?

A D-SNP is a Medicare Advantage prescription drug (MAPD) plan for consumers who are entitled to both Medicare (Title XVIII) and Medical Assistance from a state plan under Title XIX (Medicaid). D-SNPs are specialized Medicare plans for people who have both Medicare and Medicaid, also known as dually eligible consumers.

What is the phone number for Anthem Mediblue Medicare Advantage?

Were Ready to Help. Have questions? Talk to a licensed agent: 855-949-3319 (TTY: 711) Monday through Friday, 8 a.m. to 8 p.m.