Forms & publications

Can't find what you need? Visit UMP Forms and publications for more documents.

2017-2018 comparison of UMP monthly premiums

This document lists the 2017 and 2018 monthly premiums for UMP members who are employees and retirees.

Publication

2018-2019 comparison of UMP monthly premiums

This document lists the 2018 and 2019 monthly premiums for UMP members who are employees and retirees.

Publication

ABA Services Authorization Form

This form is for requesting preauthorization of Applied Behavior Analysis (ABA) Therapy services.

Form

Ardon Health Specialty Drug Release Form

This is a form that members must complete and send with initial order for specialty drugs from the UMP network specialty pharmacy, Ardon Health.

Form

Ardon patient request for non-safety caps on prescription containers

Members can use this form when purchasing specialty drugs through Ardon Health to request that Ardon Health not use child-resistant caps ("safety caps") to package a member's medication.

Form

ardon-phi-disclosure-authorization-form.pdf

Ardon Health Protected health information disclosure authorization form

Form

Census data spreadsheet

Spreadsheet for employers to share demographic data

Form

Certification of a child with disability 2019

50-142-2019

After turning 26, your dependent may be eligible for enrollment under your PEBB coverage. Use this form to certify your dependent's disability and enroll them on your PEBB coverage.

Form

COE Program brochure

This flyer gives an overview of the Centers of Excellence Program in 2019 for knee and hip replacement and spine care.

Publication

Continuation Coverage Election Notice

50-801

This is the booklet you will receive when your Public Employees Benefits Board (PEBB) health coverage ends. This booklet explains how you and your dependents can continue your PEBB health coverage. To continue PEBB health coverage, you must complete the enclosed form(s) and follow the instructions.

Publication

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