Change Text Size
A- | Reset | A+

Publications & Forms

Newsletters (Active Members)

• 2024 Summer Active Newsletter
• 2024 Winter/Spring Active Newsletter
• 2023 Open Enrollment Newsletter
• 2023 Summer Active Newsletter
• 2023 Winter/Spring Active Newsletter

Benefit Booklets/Summaries

• Benefit Comparison Chart - Active Members
• Summary Plan Description - August 2024

Get Healthy

• Wellness Screening Postcard
• Wellness Screening FAQs
• Wellness Screening Tips
• Wellness Screening Comparison Chart

Prescription Drug Plan (Active & Non-Medicare Eligible Retiree Members)

• 2024 Prescription Drug Formulary
• Specialty Drug List
• Specialty Step Therapy Drug List
• Prior Authorization, Step Therapy and Quantity Limit List
• Mail Order Form
• Prescription Reimbursement Claim Form
• Allergenic Extract Claim Form

Prescription Drug Plan (REHP Medicare-Eligible Retiree Members)

• Mail Order Form

HIPAA

• HIPAA Authorization to Release Protected Health Information Form
• PEBTF Notice of Privacy Practices
• HIPAA FAQs

Forms

• PEBTF-1 COBRA Important Notice
• COBRA Change Form
• Foreign Marriage Affidavit (PEBTF-FM)
• Hearing Aid Claim Form - Active Members
• PEBTF-2 Employee Enrollment/Change Form
• PEBTF-6 Disabled Dependent Certification Form
• PEBTF-11 Active Declaration of Spouse Health Coverage for Active Members
• PEBTF-14 Adult Dependent Coverage Form
• PEBTF-36 Active Employer Benefit Verification Form for Active Members
• PEBTF-40 Direct Payment Authorization Form
• PEBTF-41 Enrollment in PEBTF Prescription Drug Plan Without PEBTF Medical Plan Coverage
• PEBTF-44 Attesting to Other Coverage Due to a Plan Change Effective 4/1/2021 Through 12/31/2021

Archived Publications

• 2022 Open Enrollment Newsletter
• 2022 Summer Active Newsletter
• 2022 Winter/Spring Active Newsletter
• 2021 Open Enrollment Newsletter
• 2021 Summer Active Newsletter
• 2021 Winter Active Newsletter
• 2020 Open Enrollment Newsletter
• 2020 Summer Active Newsletter
• 2020 Winter Active Newsletter
• 2019 Open Enrollment Newsletter
• 2019 Summer Active Newsletter
• 2019 Spring Active Newsletter
• 2019 Winter Active Newsletter

Adobe Acrobat Reader is required to view PDF files.