- Plan Administrator completes Section 1, 2 and 3 of the Notice of Change Form
- Fax a copy of this form 1-877-464-0109 or email firstname.lastname@example.org.
- Retain the original for your files. We recommend that you keep the application for a period of one year following the termination date
- Ensure the Plan Member's pay-direct drug/id card is returned and destroyed on the effective date of termination (if applicable)