Forms & publications

Census data spreadsheet

Spreadsheet for employers to share demographic data

Form

Certification of dependent with a disability 2018

50-142-2018

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

Form

COBRA and Continuation Coverage monthly premiums 2018

2018 Monthly premiums for PEBB COBRA and Continuation Coverage (LWOP).

Publication

COBRA election/change form (continuation of coverage) 2018

50-245F-2018

Use this form to enroll in or change your enrollment options for COBRA coverage.

Form

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

Continuation coverage election/change form (for Leave Without Pay) 2018

50-135F-2018

Use this form to enroll in or change your enrollment options for continuation coverage (LWOP).

Form

Declaration of tax status 2018

50-704-2018

Employees and retirees must complete and submit this form with their enrollment form when enrolling an individual on their PEBB Program coverage who does not qualify as their dependent for federal tax purposes.

Form

Delta Dental (DeltaCare and Uniform Dental Plan) preauthorization requirements

Preauthorization requirements for DeltaCare and Uniform Dental Plan (administered by Delta Dental of Washington). 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. 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.

Publication

DeltaCare Certificate of Coverage (COC) 2018

This benefits book describes what is covered under DeltaCare, including dental services as well as specific services not covered by the plan, finding preferred providers and how much you’ll pay, including deductibles, coinsurance, and copays. It also includes how to request an appeal and how to submit a claim.

Publication

Dental benefits comparison 2018

This chart briefly compares the per-visit costs of some in-network benefits for PEBB plans. Some copays and coinsurance do not apply until after you have paid your annual deductible. For information on specific benefits and exclusions, refer to the dental plan’s certificate of coverage or contact the plan directly.

Publication

Pages