Benefits and coverage by plan

Get plan benefits booklets, find out what is covered, and your costs for care.

What is a benefits booklet?

The benefits booklets, also called an evidence of coverage (EOC) or a certificate of coverage (COC), are produced by the health plans to provide detailed information about plan benefits and what is and is not covered. They are the primary source of coverage provisions offered under the plan.

What is a summary of benefits and coverage (SBC)?

Summaries of benefits and coverage (SBCs) are required under the federal Affordable Care Act to help members understand plan benefits and medical terms. SBCs are not available for Medicare Advantage plans and Medicare supplement plans. For PEBB Program Medicare plan summaries, use the Medical Benefit Comparison tool.

SBCs help you compare things like:

  • Whether there are services a plan doesn't cover
  • What isn't included in a plan's out-of-pocket limit
  • Whether you need a referral to see a specialist

The PEBB Program and/or medical plans provide SBCs, or notice of how to get one, at different times throughout the year (like when you apply for coverage, renew your plan, or request an SBC). SBCs are available (upon request) in English, Spanish, Tagalog, Chinese, and Navajo.

SBCs don't replace the PEBB Program's Medical Benefit Comparison tool, or the plans' benefits booklet.

SBCs are not available for Medicare Advantage plans and Medicare supplement plans. For PEBB Medicare plan summaries, use the Medical Benefit Comparison tool or the Medicare Benefits At-a-Glance.

What are preauthorization criteria?

Preauthorization is when you seek approval from your health plan for coverage of specific services, supplies, or drugs before receiving them. Some services or treatments (except emergencies) may require preauthorization before the plan pays for them. Preauthorization is not a guarantee, however, that your plan will pay for those services, supplies or drugs.

The criteria included in the preauthorization requirements below state how a plan determines when a service, supply, or drug is medically necessary and will be covered.

Kaiser Permanente NW documents

Kaiser Foundation Health Plan of the Northwest offers plans in Clark and Cowlitz counties in Washington, and select counties in Oregon.

Evidence of Coverage (EOC)

Non-Medicare retiree plans

2024

2023

Medicare retiree plan (COBRA only)

2024

2023

Summary of Benefits and Coverage

Non-Medicare retiree plans

2024

2023

Preauthorization criteria

Kaiser Permanente NW preauthorization requirements

These criteria do not imply or guarantee approval. Please check with your plan to ensure coverage. Preauthorization requirements are only valid for the month published. They may have changed from previous months and may change in future months.

Kaiser Permanente WA documents

Kaiser Foundation Health Plan of Washington.

Evidence of Coverage (EOC)

Non-Medicare retiree plans

2024

2023

Medicare retiree plans (COBRA only)

2024

2023

Summary of Benefits and Coverage

Non-Medicare retiree plans

2024

2023

Preauthorization criteria

These criteria do not imply or guarantee approval. Please check with your plan to ensure coverage. Preauthorization requirements are only valid for the month published. They may have changed from previous months and may change in future months.

Premera Blue Cross Medicare Supplement plan documents

Medicare retiree plan

Uniform Medical Plan documents

Certificate of Coverage (COC)

Non-Medicare retiree plans

2024

2023

Medicare retiree plan (COBRA only)

2024

2023

Summary of Benefits and Coverage

Non-Medicare retiree plans

2024

2023

Medicare (COBRA only)

2024

2023

Preauthorization criteria

Regence preauthorization requirements (for UMP plans)

These criteria do not imply or guarantee approval. Please check with your plan to ensure coverage. Preauthorization requirements are only valid for the month published. They may have changed from previous months and may change in future months.

Washington State Rx Services preauthorization requirements (for pharmacy)

These criteria do not imply or guarantee approval. Please check with your plan to ensure coverage. Preauthorization requirements are only valid for the month published. They may have changed from previous months and may change in future months.

UnitedHealthcare documents

Evidence of Coverage

2024

2023