Forms & publications

A summary of what the PEBB Kaiser Permanente WA Classic plan covers and what it costs.

This is the Long-term Disability (LTD) Certificate of Coverage (COC) for Public employees in PEBB benefits. It includes information on eligibility, enrollment, exclusions, and premiums.

The chart briefly compares the medical deductibles and per-visit out-of-pocket costs of some in-network benefits for PEBB medical plans. Copays and coinsurances may apply; some copays and coinsurance do not apply until after you have paid your annual deductibles. Call the plans for more information on specific benefits, including preauthorization requirements and exclusions. If anything in these charts conflicts with the plan’s benefits book, the benefits book takes precedence.

This is the MetLife accidental death and dismemberment (AD&D) insurance certificate of coverage (COC) for PEBB employees.

This is the MetLife life insurance certificate of coverage (COC) for PEBB employees

Use this form to name the persons or entities you want to receive your life insurance proceeds after your death. Return this form to MetLife.

Use this form to notify MetLife that you wish to cancel your Supplemental Life Insurance and/or Supplemental Accidental Death & Dismemberment (AD&D) Insurance. For employees only: Employee Basic Life Insurance ($35,000) and Employee Basic AD&D Insurance ($5,000) is not affected by this form. It is provided by your employer at no cost to you. You cannot cancel your Employee Supplemental Life Insurance and keep Dependent Life Insurance.

This benefits book describes what is covered as a PEBB member under MetLife 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.

Preauthorization requirements for MetLife 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.

Use this form if you are requesting an appeal of a decision.