Your Benefits Resources
We want to ensure our members and their families to get the most out of the benefits we provide them by providing the most up-to-date library of resources.
Health and Welfare Plan Resources
Forms
Complete this questionnaire if you and/or your dependent have been involved in an accident where an injury required medical attention.
Log into your Member Portal to update your address, or
Complete this pdf form to update your address and return it to Carpenters Benefit Office.
Complete this form to designate a person (or persons) to receive benefits that may be payable upon your death. Important: If beneficiaries are not designated as either primary or secondary, all beneficiaries are considered to be primary by default.
Beneficiary Form (Spanish PDF)
The Beneficiary Form may be completed online using our Member Portal.
Complete this form to submit a request for out-of-network claim reimbursement to Cigna for medical care charges incurred at a non-Cigna provider for dates through 12/31/2022.
Complete this form to provide information about you and your eligible dependents. This form must be completed and submitted any time family information changes. New members will also need to complete a Beneficiary Form and HIPAA Form.
The Enrollment Form may be completed online using our Member Portal.
Complete this form to submit prescriptions to Express Scripts for reimbursement when a non-network pharmacy is used or to coordinate benefits when another prescription plan has already paid their portion of the prescription bill.
Complete this form to submit prescriptions to Express Scripts Home Delivery.
Complete this form to authorize the St. Louis Benefit Plans Office to release PHI/ePHI to the individual or entity listed on the form.
The HIPAA Form may be completed online using our Member Portal.
Complete this form to revoke or terminate permission to disclose PHI/ePHI to a previously authorized person or entity.
HIPAA Revocation Form (Spanish PDF)
The HIPAA Revocation Form may be completed online using our Member Portal.
Print and complete this form if you have been called to or are returning from active military duty. This form allows you to freeze your health and welfare coverage while you are away and reinstate your coverage upon your return.
Complete this form if plan dependents have other insurance in order for Carpenters Health Plan to coordinate benefits appropriately.
Both the member and physician must complete this form in order for the member to be considered for weekly benefits due to a non-work-related accident/illness.
Both the member and physician must complete this form in order for the member to be extend weekly benefits due to a non-work-related accident/illness.
Short-Term Disability Form – Subsequent Statement of Claim (PDF)
Use this form to authorize direct deposit of your short-term disability benefits into your checking or savings account.
Complete this form to provide the Plan with insurance coverage information for both a working and non-working spouse in order to be eligible for Carpenters’ coverage.
Spousal Coverage Verification Form (PDF)
Spousal Coverage Verification Form (Spanish PDF)
The Spousal Coverage Verification Form may be completed online using our Member Portal.
Complete this form to submit a request for out-of-network claim reimbursement to UMR for medical care charges incurred at a non-UnitedHealthcare provider beginning 1/1/2023.
Complete this form to submit a request for out-of-network claim reimbursement to VSP for eye care charges incurred at a non-VSP provider.
Self-Pay
Read more about the COBRA Continuation of Coverage rights available in the event of a Qualifying Event.
The Plan permits self-payments by underemployed, retired, disabled, and Self-Employed Members and Surviving Spouses, as well as COBRA continuation Premiums.
Use this packet to complete your application to continue coverage under the Self-Pay provision of the Plan.
Read more about Minimum Difference payment guidelines.
Use this form to set up a recurring payment using your bank account or pension benefit deduction (St. Louis or Kansas City only).
Self-Payment Authorization Form (PDF)
To set up a recurring payment or to make a one-time payment using your bank account or credit card, use our Member Portal.
Plan Documents & Federal Notices
Plan Description & Summary
- Health and Welfare Plan Document and Summary Plan Description (PDF)
- Health and Welfare Summary of Material Modifications (PDF)
- Premium Plan Schedule of Benefits eff 5/1/2023 (PDF)
- Basic Plan Schedule of Benefit eff 7/1/2023 (PDF)
- Carpenters Wellness Center Schedule of Benefits
- Delta Dental Member Appeals Procedure (PDF)
- Health Plan Board of Trustees as of 1/1/2024 (PDF)
Federal Notices
- Premium Plan Summary of Benefits and Coverage (SBC) Effective January 1, 2025 (PDF)
- Basic Plan Summary of Benefits and Coverage (SBC) Effective January 1, 2025 (PDF)
- Premium Plan Summary of Benefits and Coverage (SBC) Effective January 1, 2024 (PDF)
- Basic Plan Summary of Benefits and Coverage (SBC) Effective January 1, 2024 (PDF)
- Summary of Benefits and Coverage (SBC) Uniform Glossary (PDF)
- Summary Annual Report - 2023 Plan Year (PDF)
- Summary Annual Report - 2022 Plan Year (PDF)
- HIPAA Privacy Practices (PDF)
- Womens Health and Cancer Rights Act (PDF)
Flyers
- Carpenters Health Plan Spousal Coverage Program (PDF)
- Mercy MAP Program (English PDF)
- Mercy MAP Program (Spanish PDF)
- Mercy Member Assistance Program (MAP) Rack Card (PDF)
- Express Scripts Online & Mobile App Registration Instructions (PDF)
- MetLife More than Life Insurance Protection (PDF)
- MetLife Empathy Resources
- VSP Essential Medical Eye Care Plan Benefits (PDF)
- Servicios de traducción de MACRBS (Español PDF)
- MACRBS Translation Services (English PDF)
- How to Access Your Member Portal (PDF)
- Your Provider Can Join the UnitedHealthcare Network (PDF)
- Find a UHC Choice Plus Provider (PDF)
- Find a UHC Choice Plus Behavioral Health Provider (PDF)
- UMR Orthopedic Health Support Program (PDF)
- UHC Choice Plus Hearing Benefit Flyer 2024 (PDF)
- UHC Choice Plus Hearing - How to Guide 2024 (PDF)
- UHC Medicare Advantage PPO 2025 Plan Guide (PDF)
- Carpenters Medicare Plan Resources brochure (PDF)
- Carpenters Medicare Explanation of Coverage
- Smoking & Tobacco Cessation Aids & Quit Resources (PDF)
- Smoking & Tobacco Cessation Aids & Quit Resources (Spanish PDF)
- UMR Health Coaching support (PDF)
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