FORMS

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General H&W Fund Forms:

Appeals Procedure

Cobra.Coverage.Letter

Creditable Coverage Letter

Delta Dental Non-Participating Claim Form

Eligibility Letter

Student Certification Form

Adult Dependent Letter (mailed to all H&W Fund participants on 12/13/10)

Adult Dependent Enrollment Form

Notice of Grandfathered Status

NVA Non-participating Reimbursement Form

Domestic Partner Forms:

Domestic Partner Benefit Information

Domestic Partner Verification Statement

Domestic Partner Termination

Express Scripts Forms:

Express Scripts 2012 Formulary

Express Scripts 2011 Formulary

Express Scripts Reimbursement Form

Prior Authorization Base and Supplemental List (.doc)

Drug Quantity Limits List (.doc)

Express Scripts Prescription Order Form

For Your Benefit Newsletter

Bucks County Files:

Bucks County Hearing Aid Reimbursment Benefit

Bucks County Hearing Aid Claim Form

Bucks County Retiree.Letter.011811

Bucks County Retiree Health Reimbursement Arrangement Summary.Revised.Dec2011

Bucks County Retiree HRA Claim Form

Bucks County Retiree HRA Claim Form Expense Eligibility

Bucks County Retiree-Verification Form

Bucks County Life/AD&D Beneficiary Form

Bucks County Life/ADD Booklet

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