Duplicate Coverage Disclosure for Coordination of Benefits Form (You are obligated to keep PEHP informed of medical/dental coverage that you or an eligible family member have that is not with PEHP. Use this form to provide this information and any related changes. Learn more about “Other Coverage” and “Coordination of Benefits” here)
Wellness Rebate Forms
Other rebates you may be eligible to earn:
- Diabetes Management ($100) - If you have been diagnosed with diabetes.
- PEHP WeeCare Rebate ($50) - If you are an expectant mother.
- Tobacco Cessation ($50) - If you currently use tobacco or have used tobacco within the past 6 months.
FLEX and HRA Forms
FLEX Claim Form - No Grace Period