ET-4938
Form Active Employee / Retiree / Other Benefit Recipient

Appeal Form

Submit this completed form to ETF to appeal a determination regarding your ETF-administered benefit(s).

Preventive Drugs Covered at 100%

Learn which preventive drugs are covered at 100% for non-Medicare members.

Program Option
  • Local Annuitant Health Program (LAHP)
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
  • State Employee and Retiree Health Plan & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local High Deductible Health Plan (PO17) & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits