Forms & publications

Certificate of coverage for Premera Medicare Supplement Plan G for those eligible by age.

Certificate of coverage for Premera Medicare Supplement Plan F, by reason of disability.

Use this form to enroll in Medicare Supplement Plan G administered by Premera.

Certificate of coverage for Premera Medicare Supplement Plan G for those eligible by age.

Certificate of coverage for Premera Medicare Supplement Plan G for those eligible by disability.

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

This is the 2024 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.

Preauthorization requirements for UMP plans (administered by Regence). This document includes: Guidelines, inpatient admissions, radiology, sleep, physical medicine, lab, maternity medicine, and genetic testing. 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.

Preauthorization requirements for UMP plans (administered by Regence). This document includes: Substance use disorder, mental health, DME, surgery and transplants. 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.

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.