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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

Newsletters (Retiree Members)

• 2024 Summer Retiree Newsletter
• 2024 Winter/Spring Retiree Newsletter
• 2023 Open Enrollment Newsletter (Non-Medicare Retirees)
• 2023 Medicare Open Enrollment Newsletter
• 2023 Summer Retiree Newsletter
• 2023 Winter/Spring Retiree Newsletter

Benefit Booklets/Summaries

• Benefit Comparison Chart - Active Members
• Benefit Comparison Chart - Non-Medicare Elig. Retirees
• REHP Benefits Handbook - August 2024
• 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)

• 2024 Prescription Drug Formulary - Revision September 2024
• Formulary Exclusion List
• Evidence of Coverage - 2024
• Summary of Benefits - 2024
• Annual Notice of Change - 2024
• Mail Order Form
• Prescription Reimbursement Claim Form
• Allergenic Extract Claim Form

HIPAA

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

Forms

• PEBTF-1 COBRA Important Notice
• REHP-1 COBRA Important Notice for Retiree Members
• 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-11 Retiree Declaration of Spouse Health Coverage for Retiree Members
• PEBTF-14 Adult Dependent Coverage Form
• PEBTF-36 Active Employer Benefit Verification Form for Active Members
• PEBTF-36 Retiree Employer Benefit Verification Form for Retiree 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

Health Plans Only

• Outgoing Eligibility v5010 Benefit and Enrollment Maintenance 834
• EDI Companion Guide
• 999 Implementation Guide

Archived Publications

• 2022 Open Enrollment Newsletter
• 2022 Open Enrollment Newsletter (Non-Medicare Retirees)
• 2022 Medicare Open Enrollment Newsletter
• 2022 Summer Active Newsletter
• 2022 Summer Retiree Newsletter
• 2022 Winter/Spring Active Newsletter
• 2022 Winter/Spring Retiree Newsletter
• 2021 Open Enrollment Newsletter
• 2021 Open Enrollment Newsletter (Non-Medicare Retirees)
• 2021 Medicare Open Enrollment Newsletter
• 2021 Summer Active Newsletter
• 2021 Summer Retiree Newsletter
• 2021 Winter Active Newsletter
• 2021 Winter Retiree Newsletter
• 2020 Open Enrollment Newsletter
• 2020 Open Enrollment Newsletter (Non-Medicare Retirees)
• 2020 Medicare Open Enrollment Newsletter
• 2020 Summer Active Newsletter
• 2020 Summer Retiree Newsletter
• 2020 Winter Active Newsletter
• 2020 Winter Retiree Newsletter
• 2019 Open Enrollment Newsletter
• 2019 Open Enrollment Newsletter (Non-Medicare Retirees)
• 2019 Medicare Open Enrollment Newsletter
• 2019 Summer Active Newsletter
• 2019 Summer Retiree Newsletter
• 2019 Spring Active Newsletter
• 2019 Spring Retiree Newsletter
• 2019 Winter Active Newsletter
• 2019 Winter Retiree Newsletter

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