Category: Benefit Forms

Express Scripts COB Form

Complete this form to submit a claim to for pharmacy purchases. Express Scripts Rx Reimbursement and Coordination of Benefits Claim Form

Express Scripts by Mail

Complete this form to submit a prescription by mail to Express Scripts to the address listed on the claim form. Express Scripts by Mail form

PEHP Healthy Utah and Wellness Rebates

For the most recent PEHP Healthy Utah “Know and Plan”, “Good for You” and other wellness rebate forms, please click on the link below to be directed to the Healthy Utah Forms section of the PEHP web site.  You will not be required to log in to access these forms. Healthy Utah Forms

Savings Plans Direct Deposit for One-time Payments

Use this form for a direct deposit of one-time payments from your Utah Retirement Systems (URS) Savings Plans (401(k), 457, and IRAs). Completed forms can be sent directly to URS at fax number 801-366-7445. URS Savings Plans Direct Deposit for One-time Payments

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URS Tier I Request for Exemption

This form is to be completed for position that are exempt from service credit accrual. URS Tier 1 Request for Exemption

Military Leave Worksheet

This form is for employees who will be out on Military Leave (after 15 days of Military Leave has been exhausted).  The form allows the employee to select options for payment of premiums during military leave and designates how much personal leave the employee would like to use. Military Leave Form (Excel) Military Leave Form (PDF)

URS Tier II Request for Exemption Form

Complete this form to opt out of Tier II defined contribution vesting. Completed forms can be sent directly to Utah Retirement Systems (URS) at fax number 801-366-7759. URS Tier II Request for Exemption Form

URS Statement of Ineligibility

This form notifies URS when an employee is not eligible for retirement benefits and also notifies the employee they can contribute on their own to a 401k account if they choose to do so.  This certification is normally part of the Onboarding process completed by the Employee Resource Information Center. URS Statement of Ineligibility 1/2014