PEBB nondiscrimination statement and language access notice

57-401

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

Publication

PEBB, SEBB, and UMP language assistance insert (HCA 57-245)

57-245

This document provides language access information (including who to contact for interpreters and translation of printed materials) for public employees (PEBB), school employees (SEBB), and UMP members (in 20 languages).

Publication

Premium Payment Plan Election/Change Form (PEBB)

50-185

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

Form

Premium surcharge attestation change form (PEBB) 2020

50-563

This is the 2020 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.

Form

Premium surcharge attestation change form 2019

50-563-2019

This is the 2019 Premium Surcharge 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.

Form

Premium surcharge attestation help sheet (PEBB) 2019

50-226-2019

This is the 2019 Premium Surcharge Attestation Help Sheet. Use the information on this help sheet to attest on your enrollment form or the Premium Surcharge form whether the premium surcharges for tobacco use or spouse/state-registered domestic partner apply.

Form

Premium surcharge attestation help sheet (PEBB) 2020

50-226

This is the 2020 Premium Surcharge Attestation Help Sheet. Use the information on this help sheet to attest on your enrollment form or the Premium Surcharge form whether the premium surcharges for tobacco use or spouse/state-registered domestic partner apply.

Form

Regence (UMP [PEBB] plans) preauthorization requirements (Laboratory, Maternity, and Medicine)

Preauthorization requirements for UMP plans (administered by Regence). 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

Regence (UMP [PEBB] plans) preauthorization guidelines

Preauthorization guidelines for UMP plans (administered by Regence). 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

Regence (UMP [PEBB] plans) preauthorization requirements (Durable Medical Equipment)

Preauthorization requirements for Uniform Medical Plans (PEBB) (administered by Regence). 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

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