IBEW District 8

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Health Care Documents

Health Care Forms

	ACH Form (Retiree - Selfpay)

	Address Change Form

	Beneficiary Designation Form – Health

	Coordination of Benefits

	Death Beneifits Application

	Cigna Claim Form

	Express Scripts Claim Form

	Life Insurance Affidavit (Template)

	New Member Packet - New Hire

	Retiree Application Packet

	Temporary Total Disability

	Enrollment Form - Active Regular

	Enrollment Form - Active Non-Bargaining

	Enrollment Form - Active Basic

	COBRA Continuation Coverage Election Form

	PCA Reimbursement Form

	Vision Reimbursement Claim Form

	COBRA Rate Changes Eff. 06.01.2023

Health Care Recent Mailings

	HW - Covid-19 Mailing

	PCA Substantiation Letter

	Amendment 21 SMM - Eff 1-1-20

	Amendment 22 SMM - Eff 1-1-20 - Combined

	Amendment 23 SMM

	Amendment 24 - SMM Combined Retiree Elgibility Telehealth Ext

	Amendment XX - SMM Extended Expanded Telehealth 3-31-21 Increased Vision

	BeneSys ARP Subsidy Summary and Application

	COVID-19 Mailing

	Mobile App Notice

	SMM - Covid Vaccine

	SMM - Telehealth - ER Copayment Waiver

	Amendment 26 SMM - High Tech Radiology

	SMM - Weekly Disability Increase effective 01-01-2023

	SMM - IRS Allowable Charges from Personal Care Accounts

	Retiree Self-Payment Rates eff. 01-01-2023

	COBRA Rate Change eff. 06/01/2023

Health Care Amendments and Changes

Health Care Documents / Summary Plan Description

	Benefit Fund Summary Plan Description eff. January 1, 2014

	Basic Plan Summary Plan Description 3-1-2018

	Doctor On Demand Flyer

	Dr. On Demand 8th Dst. Member Registration Guide

	IBEW 8th District - Notice Letter - DOCTOR ON DEMAND, INC. DBA INCLUDED HEALTH

	Hello Heart Registration Flyer

Summary of Benefits and Coverages

	MetLife Dental Plan Summary - All States Except Montana and Wyoming

	MetLife Dental Plan Summary - Montana and Wyoming Only

	2023 Regular Plan SBC

	2023 Basic Plan SBC

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