Medicare Plan Insurance Change Form pdf format of medicarechangeform.pdf
- If you are an existing state or municipal retiree or survivor already enrolled in a GIC Medicare plan, use this form to change your plan election during Annual Enrollment.  In order to use this form, both you and your covered spouse, if applicable, must already be enrolled in a GIC Medicare plan.

Under Age 65 or Over Combination Coverage – if you and your covered spouse have combination Medicare/Non-Medicare plan coverage, write to the GIC to request a plan change during Annual Enrollment.  You must enroll in one of the GIC plan combination coverage options for State/Municipal Retirees or RMTs/EGRs.  For written requests to make a health plan change, include your name, address and GIC Identification Number and mail to the GIC, P.O. Box 8747, Boston, MA  02114-8747 

This information provided by the Group Insurance Commission .