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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.

2025 Keystone 65 HMO

Keystone 65 HMO Change Form

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

2025 Personal Choice 65 PPO

Personal Choice 65 PPO Change Form

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’d like to switch or leave your current health plan, below are the disenrollment forms available to you. Not all plan changes require a form, and there are only certain times of year that you can switch plans throughout the year. Please read these important instructions regarding requesting disenrollment from the plan.

Medicare Advantage disenrollments

When can I make changes to my Medicare coverage?

  • Annual Enrollment Period (AEP) from October 15 through December 7 each year: Anyone can make any type of change for the following year including adding or dropping Medicare prescription drug coverage or changing to a new Medicare Advantage plan. The effective date for the newly selected plan is January 1 of the following year.
  • Open Enrollment Period (OEP) from January 1 through March 31 each year: Anyone enrolled in a Medicare Advantage plan (except for a Medicare Medical Savings Account/MSA) has an opportunity to enroll in a different Medicare Advantage plan or disenroll from their Medicare Advantage plan and return to Original Medicare. The effective date of the disenrollment from the MA plan is the first day of the month following the date the disenrollment request is received. Disenrollment requests received by MA organization in January are effective February 1; those received in February are effective March 1; and those received in March are effective April 1. The OEP does not provide an opportunity for those enrolled in Original Medicare to enroll in a Medicare Advantage plan, nor does it allow for Part D changes for individuals enrolled in Original Medicare, including those enrolled in stand-alone Part D plans.
  • Special Exceptions: You are unable to make changes at other times of the year, unless you meet certain special exceptions, such as moving out of the plan's service area, joining a plan in your area with a 5-star rating, or qualifying for extra help with your prescription drug costs. If you qualify for extra help with your prescription drug costs you may enroll in, or disenroll from, a plan at any time. If you lose this extra help during the year, your opportunity to make a change continues for two months after you are notified that you no longer qualify for extra help.

Extra help in paying for your insurance plan
People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify, Medicare could pay for your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify won't have a coverage gap or a late enrollment penalty. Many people qualify for these savings and don't even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at https://www.ssa.gov/medicare/part-d-extra-help.

Learn more about money saving programs.

When should I fill out the disenrollment request form?
You should fill out the appropriate disenrollment form during a valid election period, if you want to change to Original Medicare only and do not want Medicare prescription drug coverage.

You shouldn't fill out the appropriate disenrollment form if you are planning to enroll, or have enrolled, in another Medicare Advantage plan or other Medicare health plan. Enrolling in another Medicare plan will automatically disenroll you from our plan.

You shouldn't fill out the appropriate disenrollment form if you are enrolling in a Medicare prescription drug plan. Enrolling in a Medicare prescription drug plan will automatically disenroll you from the plan to Original Medicare.

Until your disenrollment date, you must keep using the plan's doctors. To avoid any unexpected expenses, you may want to contact us to make sure you've been disenrolled before you seek medical services outside of the plan's network.

How do I submit the disenrollment request?
If you want Original Medicare, as described above, you may fill out the appropriate disenrollment form during a valid election period, sign it, and send it back to us at:

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

You can also fax the form with a readable signature and date to us at 1-215-241-2275.

You can call 1-800-MEDICARE (1-800-633-4227) for information and help choosing a Medicare plan available in your area. TTY users should call 1-877-486-2048, 24 hours a day/7days a week.

2025 Medicare Advantage disenrollment forms

 

What are my Medigap rights?

If you will be changing to Original Medicare, you might have a special temporary right to buy a Medigap policy, also known as Medicare supplemental insurance, even if you have health problems. For example, if you are age 65 or older and you enrolled in Medicare Part B within the past 6 months or if you move out of the service area, you may have this special right.

Federal law requires the protections described above. Your state may have laws that provide more Medigap protections. If you have questions about Medigap or Medigap rights in your state, you should contact your State Health Insurance Program, Medicare Education and Decision Insight, or PA MEDI, at 1-800-783-7067. You can also call 1-800-MEDICARE (1-800-633-4227) anytime, 24 hours a day, 7 days a week for more information about trial periods. TTY users should call 1-877-486-2048.

If you need any help, please contact the Member Help Team.

Medicare Supplement (Medigap) disenrollments

Please complete the following form to cancel Security 65 or MedigapSecurity plan coverage. Once you have completed and signed the form, please mail or fax to:

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

Fax: 215-238-2289

Cancellation Request Forms (without Estate)

Cancellation Request Forms (with Estate)

EFT form

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Website last updated: 7/2/2025