Forms & publications

Can't find what you need? Visit UMP Forms and publications for more documents.

Kaiser Permanente WA Value Certificate of Coverage (COC) 2019

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.

Publication

Kaiser Permanente WA Value Summary of Benefits and Coverage (SBC) 2019

A summary of what the Kaiser Permanente WA Value plan covers and what it costs.

Publication

Medical 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.

Publication

Medical Claim Form

This form is for sending in a claim for medical services for all Uniform Medical Plans.

Form

Medicare Advantage disenrollment form (form D) 2019

51-556-2019

Use this form to disenroll from Medicare Advantage.

Form

Medicare Advantage plan election form (form C) 2019

51-576-2019

Use this form to enroll in Medicare Advantage plans.

Form

Medicare 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. Call the plans directly for more information on specific benefits, including preauthorization requirements and exclusions. Kaiser Permanente NW and Kaiser Permanente WA offer Medicare Advantage plans, but not in all areas.

Publication

Medicare supplement plan F benefits 2019 (outline)

Outline of Medicare Supplement Plan F Coverage. Shows the benefits included in each of the standard Medicare supplement plans.

Publication

MetLife beneficiary designation

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.

Form

MetLife cancellation of life insurance - retiree

51-857

Use this form to notify MetLife that you wish to cancel your Retiree Life Insurance. If you cancel your Retiree Life Insurance, you may not reenroll in life insurance unless you regain eligibility for life insurance at a later date.

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