Friday, March 24, 2023

Health Care Documents

Health Care Forms
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
COBRA Rates effective 06/01/2022
PCA Reimbursement Form
Vision Reimbursement Claim Form
Health Care Recent Mailings
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
Health Care Amendments and Changes
Health Care Amendments and Changes
Basic Plan SPD Amendment 1
Basic Plan SPD Amendment 2
Basic Plan SPD Amendment 3
Basic Plan SPD Amendment 4
Basic Plan SPD Amendment 5
Basic Plan SPD Amendment 6
SPD Health Amendment 1
SPD Health Amendment 2
SPD Health Amendment 3
SPD Health Amendment 4
SPD Health Amendment 5
SPD Health Amendment 6
SPD Health Amendment 7
SPD Health Amendment 8
SPD Health Amendment 9
SPD Health Amendment 10
SPD Health Amendment 11
SPD Health Amendment 12
SPD Health Amendment 14
SPD Health Amendment 13
SPD Health Amendment 15
SPD Health Amendment 16
SPD Health Amendment 17
SPD Health Amendment 18
SPD Health Amendment 19
SPD Health Amendment 20
SPD Health Amendments 21 & 22
SPD Health Amendment 23
SPD Health Amendment 24
SPD Health Amendment 25
SPD Health Amendment 26
Health Care Documents / Summary Plan Description
Health Care Documents / Summary Plan Description
Basic Plan Summary Plan Description 3-1-2018
Benefit Fund Summary Plan Description 1-1-2014
Doctor On Demand Flyer
Dr. On Demand 8th Dst. Member Registration Guide
IBEW 8th District - Notice Letter - DOCTOR ON DEMAND, INC. DBA INCLUDED HEALTH
Summary of Benefits and Coverages
Summary of Benefits and Coverages
MetLife Dental Plan Summary - All States Except Montana and Wyoming
MetLife Dental Plan Summary - Montana and Wyoming Only
2021 Basic Plan SBC - Effective 01-01-21 to 12-31-21
2021 Reguar Plan SBC - Effective 01-01-21 to 12-31-21
2022 Basic Plan SBC - Effective 01-01-22 to 12-31-22
2022 Regular Plan SBC - Effective 01-01-22 to 12-31-22