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Forms & publications
Can't find what you need? Visit UMP Forms and publications for more documents.
2017-2018 comparison of UMP monthly premiums
This document lists the 2017 and 2018 monthly premiums for UMP members who are employees and retirees.
Publication2018-2019 comparison of UMP monthly premiums
This document lists the 2018 and 2019 monthly premiums for UMP members who are employees and retirees.
PublicationCertification of a child with disability 2019
50-142-2019After 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.
FormChronic Opioid Attestation form
This form is for provider use. Use of opioids for more than 42 days may be authorized in 12 month intervals when the prescriber signs this attestation form. If a prescriber wants an attestation to be authorized for less than 12 months, the prescriber can include a specific end date on the form.
FormDeclaration of tax status 2019
50-704-2019Employees 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) 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 Certificate of Coverage (COC) 2019
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 2019
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 directly.
PublicationEmployee authorization for payroll deduction to health savings account (HSA) 2019
50-098-2019Use 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 guide 2019
50-100Guidance on PEBB Program benefits available to eligible employees and their dependents.
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