When submitting applications for Enrollment please follow the guidelines below:
This SDP-Health-Application and Attestation is for all SDP provided medical and health plans. You may need to contact your union for prescription, dental and vision benefits.Complete all sections in entirety. Visit the Independence Blue Cross site for up to date information on all Independence Blue Cross plans.
Please refer to General Documentation Required section for a list of documents that may need to accompany your completed application. The completed application and documentation, if required, can be faxed in to the Benefits Office at (215) 400-4631 or emailed to firstname.lastname@example.org. Please call (215) 400-4630 to confirm receipt if submitting by fax.
- SDP-Health-Application and Attestation
- Request to Remove Spouse or Dependent
- Personal Choice Out of Network Claim Form
- Exchange Notice
- PFT & Local 634 Members Vision coverage is provided by your union. If you are enrolled in Keystone medical coverage, you have additional vision coverage through Davis Vision hmo-benefit
- CASA, SPAP and Non-Represented Employees: Vision Rider Program Overview
- Non Participating Provider Reimbursement Form
Dental – CASA, SPAP and Non-Represented Employees ONLY
Prescription Drugs – CASA, SPAP and Non-Represented Employees ONLY:
- Select Drug Plan Overview
- Future Scripts Mail Service Order Form
- Prescription Reimbursement Claim Form
Self- Injectable Prescription Drugs for PFT employees. Select the form corresponding to your prescription. If your prescription is not listed, use the General Direct Ship Request form. More information is available on the Self-Injectables page.
- Viscosupplementation (Hyaluronate Acid Products)
- Xolair (Omalizumab)
- Vivitrol (Naltrexone)
- Stelara (Ustekinumab)
- RSV Synagis Prolia_Xgeva (Denosumab)
- Nucala (Mepolizumab)
- Hydroxyprogesterone Caproate Injection
- General Direct Ship Request Form
- Fasenra (Benralizumab)
- Epi Pen Reimbursement Form
- Botulinum Toxins (Botox, Dysport, Myobloc, Xeomin)
Life Insurance Beneficiary Forms
- BENEFICIARY AFFIDAVIT this form is used if the named beneficiary is deceased. This form must be notarized.
- Life Conversion Form
- Hartford Change of Beneficiary
Flu Vaccine Reimbursement Form
Flexible Spending Account (FSA)
For all types of accounts ** To be sent directly to AmeriFlex
Commuter or Parking Accounts
403(b) & 457(b)
Wage Continuation (Salary Continuance)
PFT, CASA, Non-Represented, Local 634, District 1201/32 BJ and SPAP employees can only apply for Wage Continuation coverage within 30 days of date of hire or during the annual Open Enrollment period.
Name Change/Demographic Change Request
- Demographic-Change-Request. Use this form to updae name, gender or pre-fix or correct date of birth.
- Marital Status Change Request. Use this form to update your voluntary marital status, not your tax filing status. Contact the Payroll Department, email@example.com for tax filing status.
Employees must contact Payroll, firstname.lastname@example.org or 215-400-4490 to request an address change or a change in tax withholding status.
COBRA /RETIREE Coverage forms