Forms & publications

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MetLife PEBB life insurance 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 retiree Certificate of Coverage (COC) non-Washington residents 2019

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

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MetLife retiree Certificate of Coverage (COC) Washington residents 2019

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

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MetLife retiree enrollment/change form

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

Form

PEBB Certification of a child with disability 2019

50-142-2019

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.

Form

PEBB Delta 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.

Publication

PEBB dental 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.

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PEBB dental benefits comparison 2020

50-706

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.

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PEBB Kaiser Permanente NW Classic Summary of Benefits and Coverage (SBC) 2020

A summary of what the PEBB Kaiser Permanente NW Classic plan covers and what it costs.

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PEBB Kaiser Permanente NW Consumer Directed Health Plan (CDHP) Summary of Benefits and Coverage (SBC) 2020

A summary of what the PEBB Kaiser Permanente NW Consumer Directed Health Plan (CDHP) plan covers and what it costs.

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