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Enrollment Type Forms:

Delta Dental Enrollment and Change Form
Delta Dental Enrollment and Change Form (Delaware County Only)
Beneficiary Form (Bucks County Only)
Employee Enrollment and Change Form
Employee Enrollment and Change Form (Delaware County Only)

General H&W Fund Forms/Documents:

Appeals Procedure 
Creditable Coverage Letter 
Delta Dental Non-Participating Claim Form 
Adult Dependent Letter (mailed to all participants on 12/13/10)

(Effective 5/1/2014, we will no longer require the Adult Dependent Form in order to cover your adult dependents under the age of 26. If you have not provided an Adult Dependent Form before that date, your dependent may be in a terminated status. If you are unsure, please call our office to have them reinstated for benefits.)

Notice of Grandfathered Status
NVA Non-participating Reimbursement Form
Negotiation Status Form (for Business Agent Use)
New Local Unit Application (for Business Agent Use)

Summary of Benefits & Coverage (SBC):

SBC-Bucks County 2018-19
SBC-Dauphin County 2018-19
SBC-Delaware County 2018-19
SBC-Erie County 2018-19
SBC-Huntingdon Area School District 2018-19
SBC-Lackawanna River Basin Sewer Authority 2018-19
SBC-Glossary of Terms

Express Scripts Forms:

Express Scripts 2017 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 
Step Therapy Brochure

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.December.2014
Bucks County Retiree HRA Claim Form
Bucks County Retiree-Verification Form
Bucks County Life Insurance Booklet
Bucks County Accident Insurance Booklet

Click here to download Adobe Reader for use with the .pdf files.
2589 Interstate Drive
Harrisburg, PA  17110-9602
Phone: 717-526-4856
Fax: 717-651-9529
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