CALIFORNIA - Pacificare Health Systems

PART B
Voluntary Disenrollment
In the event you choose to cancel your
membership under the Secure Horizons
Group Retiree Medicare Advantage Plan, reenrollment
may not be permitted until your
next Open Enrollment Period. You should
consult with your benefits administrator
regarding the availability of other coverage
before canceling your Secure Horizons Group
Retiree Medicare Advantage Plan membership
outside of the University of California’s Open
Enrollment Period. Please note that if you
cancel your Secure Horizons Group Retiree
MA Plan, you may be eligible to enroll in
the Individual Secure Horizons Medicare
Advantage Plan. Please refer to Section 2 for
further information regarding enrollment.
As an individual Member of Secure Horizons
Medicare Advantage Plan, you will receive
the benefit package approved by Centers
for Medicare and Medicaid Services for your
county of residence, which may cover less
than the benefit package available through
the University of California, and a Health Plan
Premium may apply. For additional information
regarding benefits and Health Plan Premiums
related to individual Members, please
contact Customer Service at 1-800-228-2144,
Telecommunications Device for the Hearing
Impaired (TDHI): 1-800-685-9355.
What are your Choices if you Disenroll
from the Secure Horizons Medicare
Advantage Plan?
If you disenroll from a Secure Horizons
Medicare Advantage Plan that includes
Medicare Part D prescription drug coverage,
and you want to continue to receive Medicare
Part D prescription drug coverage, you have
several options for receiving your Medicare
benefits. Your choices include:
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Section 8 – Disenrollment From the Secure
Horizons Group Retiree Medicare Advantage Plan
Enrolling in another Medicare Advantage
Plan that offers Medicare Part D
prescription drug coverage
Enrolling in a Private Fee-For-Service Plan
that offers Medicare Part D prescription
drug coverage
Enrolling in a Private Fee-For-Service Plan
and enrolling in a Prescription Drug Plan
Returning to Original Medicare and
enrolling in a Prescription Drug Plan
For information on other health plans
available in your area, call 1-800-MEDICARE
(1-800-633-4227), (for the hearing impaired,
1-877-486-2048), 24 hours a day, 7 days a
week or visit the CMS Web site at
www.medicare.gov.
Please contact your benefits administrator
regarding their Disenrollment and move
notification policies and the possible impact
to your retiree health care coverage options
and other retirement benefits. Additionally,
please contact either the University of
California or Customer Service for more
information regarding your Disenrollment
effective date.
How to Disenroll – You may choose to end
your membership in the Secure Horizons
Group Retiree Medicare Advantage Plan for
any reason. If you wish to Disenroll:
You or your authorized representative
may request Disenrollment directly from
PacifiCare; you must send a written,
signed and dated letter to PacifiCare. If
you have any questions about the letter,
call Customer Service.
Call the national Medicare help line at
1-800-MEDICARE (1-800-633-4227), or the
hearing impaired TTY/TDD access line
1-877-486-2048, to Disenroll via the
phone.
The Effective Date of Your Disenrollment
In most cases, a written Disenrollment
request received by PacifiCare by the end
of the month will make your Disenrollment
effective the 1st of the following month. For
example, if your Disenrollment request is
received on March 31, your Disenrollment
from the Secure Horizons Group Retiree
Medicare Advantage Plan would be processed
for an effective date of April 1. There is
an exception to this general rule. The
Disenrollment date for requests made in
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
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PART B