Forms & publications

This benefits book describes what is covered under Kaiser Permanente WA Value, including medical services and prescription drugs, 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, submit a claim, and how Medicare works with your plan.

A summary of what the PEBB Kaiser Permanente WA Value 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 directly 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 and prevails.

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

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.