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Category: Health and Wellness 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

PEHP Medical, Dental and Vision Form

Complete this form to either enroll or update your PEHP Medical, Dental and Vision coverages.  The form should be sent to PEHP directly at the address listed on the form along with any required documents as needed. ACA Medical Enrollment Form Enrollment Change Form

PEHP Leave Worksheet

This form is to be completed for employees who will be out on FMLA, Leave Without Pay / Unpaid leave or for Workers Comp leave.  The form notifies PEHP of the absence and also designates which coverages the employee would like to continue.  If the employee will be out on Military Leave please use the Military LWOP form. PEHP Leave Worksheet

PEHP Exiting Employment Form

This form is to be completed by a Human Resource representative and provided to an employee either in person or via mail when an employee leaves state employment. PEHP Exiting Employment Form

HSA Election Form

If you participate in a High Deductible STAR Plan you have the option to contribute to an Health Spending (HSA) account and a Limited Flexible Spending (FSA) Account. This form allows you to designate the amount you would like withheld from your paycheck on a biweekly basis. HSA Enrollment Instructions and Form HSA Enrollment Form

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