MetLife cancellation of life insurance - retiree 2020

51-0011

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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MetLife PEBB retiree Certificate of Coverage (COC) non-Washington residents 2020

This is the MetLife PEBB retiree life insurance certificate of coverage (COC) for retirees who do not live in Washington.

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MetLife PEBB retiree life insurance Certificate of Coverage (COC) Washington residents 2020

This is the MetLife PEBB retiree life insurance certificate of coverage (COC) for retirees who live in Washington.

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MetLife retiree enrollment/change form 2020

Use this form to enroll in or change enrollment in retiree term life insurance through MetLife.

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PEBB retiree/Continuation Coverage notice of appeal

Use this form if you are requesting an appeal of a decision.

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PEBB, SEBB, and UMP language assistance insert (HCA 57-245)

57-245

This document provides language access information (including who to contact for interpreters and translation of printed materials) for public employees (PEBB), school employees (SEBB), and UMP members (in 20 languages).

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Premera Medicare supplement plan G enrollment form (Form B)

Use this form to enroll in Medicare Supplemental insurance administered by Premera.

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Premium surcharge attestation change form (PEBB) 2020

50-563

This is the 2020 PEBB Premium Surcharge Attestation Change form. Use this form to report a change that affects your surcharge for tobacco use and/or spouse or state-registered domestic partner coverage.

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Premium surcharge attestation help sheet (PEBB) 2020

50-226

This is the 2020 Premium Surcharge Attestation Help Sheet. Use the information on this help sheet to attest on your enrollment form or the Premium Surcharge form whether the premium surcharges for tobacco use or spouse/state-registered domestic partner apply.

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Regence (UMP [PEBB] plans) preauthorization requirements (Laboratory, Maternity, and Medicine)

Preauthorization requirements for UMP plans (administered by Regence). 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.

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