Forms

If you are an active employee or retiree, please log on to your E-PEBP Portal for detailed information including Plan Year 2020 documents, new voluntary product information, to enroll/make changes, or to access your HealthScope or Express Scripts single sign on accounts.

Eligibility Forms for All Plans:

• PY 2021 Insurance Marketplace Coverage Options for Eligible New Hires
• PY 2021 Insurance Marketplace Coverage Options for Ineligible New Hires
• Release of Information Authorization
• Flexible Spending Enrollment Form

Appeal Forms:

• External Review Request Form
• CDHP Internal Claim Appeal Request Level 2
• CDHP Expedited Review