Forms & publications

After 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.

This benefits book describes what is covered as a PEBB member under Davis Vision by MetLife, 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 Davis 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.

Employees 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.

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.

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.

This 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.

Use 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.

Guidance on PEBB benefits available to public employees and their dependents. This guide includes information on eligibility, enrollment, dependent verification, benefits (medical, dental, vision coverage, life insurance, long-term disability insurance, flexible spending arrangements, the dependent care assistance program, and SmartHealth wellness program), medical plan premiums, medical plans available, premium surcharges, how to change coverage, and how to file an appeal.

These are the PEBB employee premiums for medical plans offered for 2025. 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.