Forms & publications

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

This nondiscrimination statement describes how the PEBB Program and its contracted health plans comply with applicable federal civil rights laws.

Complete this form if you do not want to pay your medical premiums with pretax earnings.

This is the 2025 PEBB Premium Surcharge Attestation Change form. Use this form to report a change that affects your surcharge for tobacco use and/or spouse or state-registered domestic partner coverage.

This is the 2025 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions on your enrollment form and are wanting to enroll a spouse or state-registered domestic partner.

This is the 2025 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions on your enrollment form and are wanting to enroll a spouse or state-registered domestic partner.

Retirement questions for individuals thinking about retirement.

Members can use this form when purchasing specialty drugs through Ardon Health to request that Ardon Health not use child-resistant caps ("safety caps") to package a member's medication. Ardon Health is a member of Washington State Rx Services (WSRxS)

Ardon Health Protected health information (PHI) disclosure authorization form. Ardon Health is a member of Washington State Rx Services (WSRxS).

This is a form that members must complete and send with initial order for specialty drugs from the Uniform Medical Plan (UMP) network specialty pharmacy, Ardon Health. Ardon Health is a member of Washington State Rx Services (WSRxS).