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PEBTF - Publications

    https://www.pebtf.org/General/Publications.aspx
    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 …

PEBTF - Active Members Information: Publications

    http://www.pebtf.org/Active/Publications.aspx
    PEBTF-6 Disabled Dependent Certification Form; PEBTF-11 Active Declaration of Spouse Health Coverage for Active Members; PEBTF-14 Adult Dependent …

Pennsylvania Employees Benefit Trust Fund (PEBTF)

    https://www.aetnamedicare.com/pebtf/en/index.html
    Pennsylvania Employees Benefit Trust Fund (PEBTF) | Aetna Medicare COVID home tests As of April 4, 2022, Medicare covers up to eight over-the-counter …

INSTRUCTIONS FOR COMPLETING EMPLOYEE …

    https://www.esu.edu/human-resources/benefits/scupa/documents/19-20/Attestation_Form_-_Instructions_for_Completing_Enrollment_Change_Form.pdf
    Prior to selecting your medical plan, make sure that you review your Summary Plan Description (SPD). You may visit the PEBTF website, www.pebtf.org to view the SPD …

Attestation Form - Declaration of Spouse Health …

    https://www.esu.edu/human-resources/benefits/seiu/documents/19-20/Attestation_Form_-_Declaration_of_Spouse_Health_Coverage.pdf
    Not Employed or Self-Employed (no further action required) – Sign, date and submit the form (proceed to #5) Is your spouse a commonwealth employee or a retiree eligible for …

Forms and Resources | Providers | Geisinger Health Plan

    https://www.geisinger.org/health-plan/providers/forms-and-resources-for-providers
    Behavioral health outpatient prior authorization request form; Behavioral health services review form; Behavioral health ABA request form - As of Jan. 1, 2023 Applied Behavioral …

Pennsylvania Employees Benefit Trust Fund (PEBTF)

    https://www.insurance.pa.gov/Coverage/Documents/EHB%202017/PEBTF%202014.pdf
    Open Enrollment, you have the opportunity to select a new Medical Plan Option. The PEBTF also provides mental health and substance abuse coverage, as well as …

PEBTF outpatient referral form - Geisinger Health …

    https://www.geisinger.org/-/media/OneGeisinger/Files/PDFs/Provider/NaviNet/Forms/GHP_referral_form_100121_rev122121_fillext.pdf?la=en
    HPM50 med GHP_referral_form_112321 rev. 0622 Do not backdate PEBTF outpatient referral form . Fax completed form to . 570-214-1384. Form must be sent within five (5) …

Testing-PEBTF - Pennsylvania Insurance Department

    https://www.insurance.pa.gov/coronavirus/Pages/Testing-PEBTF.aspx
    PEBTF (Pennsylvania Employees Benefit Trust Fund) Lab testing: If you have a PEBTF plan, the COVID -19 diagnostic test is covered without copays and deductibles. The …

1.3 Spousal/Domestic Partner Eligibility - West …

    https://www.wcupa.edu/hr/benefits/documents/PEBTFSpouseDomesticPartnerEligibility.pdf
    A Declaration of Spouse/Domestic Partner Health Coverage (PEBTF-11) Form and a Coordination of Benefits (PEBTF-2A) Form must be completed any time there is a …



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