Forms & publications

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

Retiree monthly premiums 2019

These are the Public Employees Benefits Board (PEBB) medical plans offered for retirees in 2019. To the right of each plan are the monthly premiums for an individual employee, employee and spouse,* employee with child(ren), and full family. These premiums do not include the monthly premium surcharges, if applicable to your account.

Publication

Retiree/COBRA/PEBB Continuation Coverage Notice of Appeal

51-122

This form is used by Retirees and PEBB Continuation Coverage subscribers to request an appeal.

Form

Spousal plan calculator form 2019

50-027-2019

This is the 2019 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions in the 2019 Premium Surcharge Help Sheet and are wanting to enroll a spouse or state-registered domestic partner.

Form

Spousal plan calculator tool 2019 (xls)

This is the 2019 spousal plan calculator. Use this interactive calculator tool to determine if the spousal premium surcharge applies to you if you answered 'YES' to all the questions in the Premium Surcharge Help Sheet and are wanting to enroll a spouse or state-registered domestic partner on your PEBB medical.

Form

Thinking about retirement (2019)

51-535

Retirement questions for individuals thinking about retirement.

Publication

UMP Classic 2017 Certificate of Coverage (COC)

This benefits book describes what is covered under UMP Classic, 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 UMP Classic.

Publication

UMP Classic 2018 Certificate of Coverage (COC)

This book describes what is covered under UMP Classic, including medical services and prescription drugs. It describes how to find providers and how much you'll pay to see them (including your deductible and coinsurance, and out-of-pocket limit). Your COC also describes how to request an appeal and how to submit a claim.

Publication

UMP Classic 2019 Certificate of Coverage (COC)

This book describes what is covered under UMP Classic, including medical services and prescription drugs. It describes how to find providers and how much you'll pay to see them (including your deductible, coinsurance, and out-of-pocket limit). Your COC also describes how to request an appeal and how to submit a claim.

Publication

UMP Classic and UMP Plus: 2019 High-cost generic drugs

This is a 2019 list of generic prescription drugs covered at Tier 2 under UMP Classic and UMP Plus. The list is subject to change throughout the year, so check back regularly for updates.

Publication

UMP Classic and UMP Plus: Value Tier Drugs

This is a list of drugs covered under the Value Tier cost-share for UMP Classic and UMP Plus.

Publication

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