Forms & Downloads

Comprehensive list of Forms and Documents

Alphabetical list of PEIA forms and documents

Documents for Benefit Coordinators 

Premium Rates
Benefit Coordinators Reference Manual
Training & Instructional Documents
OPEB Plan Participation Standards
Other Documents

Documents for Health Care Providers

Electronic Funds Transfer Form
Preferred Provider Benefit (PPB) Plans
Prescription Drug Benefits
Medical Home Program
Comprehensive Care Partnership Program

Enrollment Forms

Preferred Provider Benefit (PPB) Plans
Medical Home Program
Comprehensive Care Partnership (CCP) Program
Mountaineer Flexible Benefits
Securian Life Insurance 

Fee Schedules & Manuals

Fee Schedules & Manuals (Current)
Fee Schedules (Historic)

Financial Reports

PEIA Actuarial Reports
RHBT Actuarial Reports
Independent Auditors Reports
Other Financial Documents


Active Members
Non-Medicare Retirees
Medicare Retirees
Health Care Providers
Requests for Proposals / Quotations / Information
Notice of Privacy Practices
Comprehensive List of Forms and Documents

Policies & Letters


Prescription Drug Benefits

Preferred Provider Benefit (PPB) Plan
Medicare Advantage Plan (Humana)
Special Medicare Plan (PEIA)

Shopper’s Guides

Shopper’s Guides (Active Members)
Medicare Shopper’s Guides

Summary Plan Descriptions

Summary Plan Descriptions (Active Members)
Medicare Advantage Plan Booklet
Special Medicare Plan Booklet

Wellness Tools

Face 2 Face Diabetes Management Brochure
Weight Management Brochure
Health Tips