For Benefit Administrators
Newsletters (Active Members)2014 Winter Active Newsletter2013 Open Enrollment Newsletter2013 Summer Active Newsletter2013 Spring Active Newsletter2013 Winter Active Newsletter2012 Open Enrollment Newsletter2012 Summer Active Newsletter2012 Spring Active NewsletterNewsletters (Retiree Members)2014 Winter Retiree Newsletter2013 Medicare Open Enrollment Newsletter2013 Open Enrollment Newsletter (Non-Medicare Retirees)2013 Summer Retiree Newsletter2013 Spring Retiree Newsletter2013 Winter Retiree Newsletter2012 Medicare Open Enrollment Newsletter2012 Open Enrollment Newsletter (Non-Medicare Retirees)2012 Summer Retiree Newsletter2012 Spring Retiree NewsletterBenefit Booklets/SummariesSummary Plan Description - July 2012Benefit Comparison Chart - Active MembersREHP Benefits Handbook March 2012CDHP Option - HRA IRS Covered Medical ExpensesBenefit Comparison Chart - Non-Medicare Elig. Retired Prior to 7/1/04Benefit Comparison Chart - Non-Medicare Elig Retired After 7/1/04Fact Sheet: Health Coverage for Domestic Partners - Retiree MembersFact Sheet: Health Coverage for Domestic Partners - Active MembersGet HealthyGet Healthy Program Requirements BrochureGet Healthy Program FAQs Physician Results Report Form (for new hires and return to benefits)Prescription Drug Plan (Active & Non-Medicare Eligible Retiree Members)2014 Prescription Drug FormularyFormulary Exclusion ListPrior Authorization, Step Therapy and Quantity Limit ListSpecialty Drug ListMail Order FormPrescription Reimbursement Claim FormAllergenic Extract Claim FormDirect Claim/COB Form - Medco (use for dates of service prior to 7/1/2012)Allergenic Extract Claim Form - Medco (use for dates of service prior to 7/1/2012)Prescription Drug Plan (REHP Medicare-Eligible Retiree Members)2014 Prescription Drug Formulary – Revised March 2014Evidence of CoverageSummary of BenefitsMail Order FormPrescription Reimbursement Claim FormAllergenic Extract Claim FormFormsCOBRA Important NoticeCOBRA Important Notice for Retiree MembersHearing Aid Claim Form - Active MembersMedical Reimbursement Plan Claim Form - For pre-7/1/04 Non-Medicare HMO MembersPEBTF-2 Employee Enrollment/Change FormPEBTF-5 Common Law Marriage AffidavitPEBTF-6 Disabled Dependent CertificationPEBTF-6RC Disabled Dependent Recertification FormPEBTF-12 Domestic Partner Verification Statement and Application for Health BenefitsPEBTF-13 Individual Domestic Partnership Termination StatementPEBTF-14 Adult Dependent Coverage FormPEBTF-16 Dependent Coverage to Age 26 Attestation FormCertification for Medically Required Vision Care BenefitForeign Marriage Affidavit (PEBTF-FM)HIPAAHIPAA Authorization to Release Protected Health Information FormPEBTF Notice of Privacy PracticesREHP Notice of Privacy PracticesHIPAA FAQsArchived Publications2011 Spring Active Newsletter 2011 Spring Retiree Newsletter 2011 Winter Active Newsletter 2011 Active & Non-Medicare Eligible Retiree Open Enrollment Newsletter2011 Medicare Eligible Retiree Open Enrollment Newsletter2011 Summer Active Newsletter2011 Summer Retiree Newsletter2010 Summer Active Newsletter2010 Retiree Summer Newsletter2010 Spring Active Newsletter2011 Winter Retiree Newsletter 2010 Spring Retiree Newsletter2010 Winter Active Newsletter2010 Winter Retiree Newsletter
Adobe Acrobat Reader is required to view PDF files.
© 2014 Pennsylvania Employees Benefit Trust Fund. All rights reserved.
Contact firstname.lastname@example.org with any questions pertaining to the web site.