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Certification of a child with a disability (PEBB) 2020
50-142After 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.
FormContinuing eligibility for PEBB benefits during the COVID-19 outbreak
Declaration of tax status (PEBB) 2020
50-704Employees and retirees must complete and submit this form with their enrollment form when enrolling an individual on their PEBB Program 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.
PublicationDeltaCare (PEBB) Certificate of Coverage (COC) 2020
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.
PublicationDental benefits comparison (PEBB) 2020
50-706This chart briefly compares the per-visit costs of some in-network benefits for PEBB plans. Some copays and coinsurance do not apply until after you have paid your annual deductible. For information on specific benefits and exclusions, refer to the dental plan’s certificate of coverage or contact the plan directly.
PublicationEmployee authorization for payroll deduction to health savings account (HSA) (PEBB) 2020
50-098Use this form to have your employer withhold money from your paychecks and deposit it into your health savings account (HSA) on a pretax basis. Check with your payroll department before submitting this form; not all employers can arrange for payroll deductions. You must be enrolled in a consumer-directed health plan (CDHP) with an HSA before you can start a payroll deduction.
FormEmployee enrollment/change for medical groups only (PEBB) 2020
52-030Use this form to enroll in or make changes to PEBB Program benefits for you and your dependents if your employer offers PEBB Program medical coverage only.
FormEmployee enrollment/change form (PEBB) 2020
HCA 50-400Use this form to enroll in or make changes to PEBB Program benefits for you or your dependents.
FormEmployee monthly premiums (PEBB) 2020
50-626These are the Public Employee Benefits Board (PEBB) Program medical plans offered for 2020. These premiums apply to employees in state agencies, higher-education institutions, and community and technical colleges. These premiums do not include the monthly premium surcharges, if applicable to your account.
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