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Certification of a Child with a Disability (PEBB) 2022
50-0142After 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.
FormCertification of a Child with a Disability (SEBB) 2022
20-0061After 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.
FormCoverage when you travel (PEBB)
56-0122Public 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.
PublicationDavis 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.
PublicationDavis 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.
PublicationDeclaration of Tax Status (PEBB) 2022
50-0704Subscribers 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.
FormDeclaration of Tax Status (SEBB) 2022
20-0087Subscribers 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.
FormDelta 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.
PublicationDelta 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.
PublicationDeltaCare (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.
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