These printable forms are in PDF format. To read and print them, you need the free Adobe Acrobat Reader (which is probably already installed in your system). Click here if you do not have Adobe Reader installed on your system.
- Address Change Form — Form for address changes.
- Glossary of Health Coverage and Medical Terms — This glossary defines many commonly used terms, but isn’t a full list.
- Privacy Notice — This is the official Privacy Notice of the Plan as required by the HIPAA regulations.
- Release of Health Information — The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects the health information of each patient. The Alaska Teamster Welfare Trust (the “Plan”) is prohibited from releasing protected health information except in very specific circumstances. You have the right to request that the Plan release your protected health information to another party (such as another family member); however, you must provide such permission in writing.
- Status Change/Special Enrollment Form — Use this form for a new enrollment, to add family members, or to change the status of a family member.
- TEAMstar Medicare Retiree Disenrollment Form — Use this form to elect to drop participation in the Alaska Teamster-Employer Welfare Plan (the “Plan”) as a Retiree or Dependent.
- Beneficiary Designation for Health Plan — Use this form to designate beneficiaries.
- Time Loss Claim Form — Claims form for Health Plan participants.
- Medical Plan Self-Payment Billing Form For Retirees — Coverage form for the Retired Participant.
- Statement of Support — Form confirming support of your children or step-children.
- COBRA – Automatic Deduction from Bank Account — This form allows you to elect automatic debit from your checking account to pay the monthly COBRA self-payment.
- OptumRx/Catamaran Mail Order Pharmacy — Mail order service is designed for those patients who require medications on a recurring basis. The medications will be mailed directly to your home.
- OptumRx/Catamaran Formulary (Preferred Drug) List — A guide to preferred drugs within select therapeutic categories for plan participants and health care providers.
- OptumRx/Catamaran Specialty Drug List — Specialty medications are generally utilized for treating unique disease conditions and are typically injectable or that otherwise require special handling considerations.
- OptumRx/Catamaran Member Reimbursement Form — Submit the reimbursement form to OptumRx along with prescription labels to receive reimbursement for medications purchased at out of network pharmacies.
- Using Your Vision Service Plan Benefit (VSP Flyer) — Vision Service Plan benefits at a glance, information on using your Vision Service Plan benefits, and more. To request reimbursement for out-of-network vision services, please complete the VSP Member Reimbursement Form and submit the reimbursement form to VSP along with a legible copy of your itemized receipt.
- HealthCare Strategies – Important Plan Information for all Eligibile Participants — As part of Alaska Teamster Employer – Welfare Trust continued efforts to provide employees with a robust, affordable health benefit plan, we have partnered with HealthCare Strategies, Inc. (HCS) to help us in our mission. Please read the enclosed information for important details regarding this program.
HRA for AILU Only
- HRA Claim Form — Claims form for HRA participants.
- Direct Deposit — Authorization for reimbursements from your Health Reimbursement Arrangement directly to your bank account.
- How to Guide — HRA mobile application instructions and online how to guide. The mobile application and secure online portal gives you 24/7 access to view information and manage your Flexible Spending Accounts.
- Medical Plan Self-payment Billing Form For Retirees — Coverage form for the Retired Participant.
- 2020 Retiree and COBRA Self-Payment Rates — Rates for the Retiree Health Plan and COBRA Coverage.
- Eligibility Rules for Retirees — Lists Retiree Health Plan eligibility requirements for the Retired Participant.
- Summary Plan Description — This is your benefits booklet known as the Summary Plan Description of the Alaska Teamster-Employer Welfare Trust for active and retired participants.
- Summary of Benefits and Coverage (SBC – Active) — This is a summary of your benefits and coverage. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.959trusts.com or by calling 1-800-478-4450.
- Summary of Material Modifications – October, 2018 — Summary of Plan Benefit Changes adopted by the Board of Trustees.
- Summary Annual Report – June 30, 2018 – Describes the status of the fund at the end of Plan Year 2018.
- Summary Annual Report – June 30, 2017 — Describes the status of the fund at the end of Plan Year 2017.
- Summary Annual Report – June 30, 2016 — Describes the status of the fund at the end of Plan Year 2016.
- Summary Annual Report – June 30, 2015 — Describes the status of the fund at the end of Plan Year 2015.
- Summary Annual Report – June 30, 2014 — Describes the status of the fund at the end of Plan Year 2014.
- Summary Annual Report – June 30, 2013 — Describes the status of the fund at the end of Plan Year 2013.
- Summary Annual Report – June 30, 2012 — Describes the status of the fund at the end of Plan Year 2012.
- Summary Annual Report – June 30, 2011 — Describes the status of the fund at the end of Plan Year 2011.
- Summary Annual Report – June 30, 2010 — Describes the status of the fund at the end of Plan Year 2010.