HRA Authorization Form

COBRA premiums for Continuation Coverage and Retiree Health Plan (RHP) self-payments are permissible expenses payable through the Southern California IBEW-NECA Health Reimbursement Arrangement (HRA) account. Complete the authorization form to authorize the processing of a one-time COBRA or Retiree Health Plan self-payment using your HRA account funds. Contact Coast Benefits directly at (844) 739-7956 or visit the HRA web portal at for additional assistance.

A new authorization form must be completed for each month of COBRA/RHP self-payment(s) you are requesting to be deducted from your HRA account. If you do not have enough funds in your HRA account for the full amount due for the COBRA or RHP self-payment, you must include the balance due with this form; or you can pay the full bill out-of-pocket and request a partial reimbursement from Coast Benefits. If additional funds are later contributed into your HRA account, you may re-submit the claim for additional reimbursement.

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