Certification of a Child with a Disability (PEBB) 2022

50-0142

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

Certification of a Child with a Disability (SEBB) 2022

20-0061

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

Form

Coverage when you travel (PEBB)

56-0122

Public Employees Benefits Board (PEBB) Program health plans have agreements with health providers at many destinations. This helps you get the medical care you may need. Contact your plan before you travel to find out about your options.

Publication

Davis Vision (SEBB) Certificate of Coverage (COC) 2022

This benefits book describes what is covered as a SEBB member under Davis vision, including vision services and specific services not covered by the plan. Finding preferred providers and how much you’ll pay, including deductibles, coinsurance, and copays.

Publication

Davis Vision (SEBB) preauthorization requirements

Preauthorization requirements for Davis Vision plan. 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

Declaration of Tax Status (PEBB) 2022

50-0704

Subscribers must submit this form with their enrollment form when enrolling an individual on their coverage who does not qualify as their dependent for federal tax purposes.

Form

Declaration of Tax Status (SEBB) 2022

20-0087

Subscribers must submit this form with their enrollment form when enrolling an individual on their coverage who does not qualify as their dependent for federal tax purposes.

Form

Delta Dental (DeltaCare and Uniform Dental Plan) (PEBB) 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

Delta Dental (DeltaCare and Uniform Dental Plan) (SEBB) 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 (PEBB) Certificate of Coverage (COC) 2022

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

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