MUST FORMS
Enrollment
Enrollment Form
Change Form
Joint Coverage Form*
Anthem Transition of Care Form
*Married employees, who are both covered by the Trust and are employed by signatory contractors to the Trust, may jointly enroll for health, dental and vision coverage. The employee whose birthday is first in the calendar year will be the primary covered employee and the other employee will be the dependent.
However, the employee who is covered as a dependent must be enrolled, as an employee for mental health and life insurance coverage; the employee may not opt out and must be covered for such benefits as an employee.
Anthem CarelonRx Forms
Anthem Medical Claim Form
Options Rider Claims
The Options Rider is a supplemental benefit for outpatient services such as physician office visits as outlined in the Summary Plan Description. Specifically excluded are inpatient services, major surgical procedures and maternity care in any setting. The Benefit Summary on the link below provides details about your coverage.
This Rider is offered only in conjunction with enrollment in the Plan’s HMO benefit. Claims must be submitted to the Administrative Office, along with a completed Claim Form, within fifteen (15) months of the date of service.
Life and AD&D Benefits
You have 31 days from the date your life insurance through Anthem terminates to apply for individual coverage. You must complete one of the Conversion Forms and submit it to Anthem with your first month’s payment. Read the Conversion Form for more information.
Conversion Form
Insurance Beneficiary Form
Accelerated Life Benefit Form
Life Waiver of Premium Form
Beneficiary Claim Form
Glossary of Health Coverage and Medical Terms
This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary Plan Description and Summary of Material Modification (SMM) for information on how to get a copy of your policy or plan document.)
QUESTIONS?
MUST is administered by PacFed Benefit Administrators (PacFed). Our bilingual staff can help you with enrollment, coverage and HMO claims.
PacFed’s core goal is to ensure that members understand their plan and how to use their benefits effectively. Our Member Services department is available Monday through Friday, 8:30 a.m. to 5:00 p.m. at 1-800-753-0222 or email Enrollment@PacFed.com.