Forms & publications

This chart briefly compares the per-visit costs of some in-network benefits for PEBB Medicare plans. Some copays and coinsurance do not apply until after you have paid your annual deductible. Call the plans for more information on specific benefits, including preauthorization requirements and exclusions.

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.

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.

This benefits book describes what is covered as a PEBB member under Davis Vision by MetLife, 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.

Preauthorization requirements for Davis Vision. 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.

This benefits book describes what is covered as a SEBB member under Davis Vision by MetLife, 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.

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.

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.

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

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.