Certification of a child with a disability (PEBB) 2020

50-142

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

Declaration of tax status (PEBB) 2020

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Employees and retirees must complete and submit this form with their enrollment form when enrolling an individual on their PEBB Program coverage who does not qualify as their dependent for federal tax purposes.

Form

Delta Dental (DeltaCare and Uniform Dental Plan) (PEBB) 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

DeltaCare (PEBB) Certificate of Coverage (COC) 2020

This benefits book describes what is covered under DeltaCare, including dental services 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 and how to submit a claim.

Publication

Dental benefits comparison (PEBB) 2020

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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.

Publication

Electronic debit service agreement (EDS) (PEBB) 2020

Electronic Debit Service (EDS) is only available to continuously enrolled self-pay PEBB subscribers. Electronic service allows PEBB subscribers to have monthly payments automatically taken from a checking or savings account.

Form

Employee authorization for payroll deduction to health savings account (HSA) (PEBB) 2020

50-098

Use this form to have your employer withhold money from your paychecks and deposit it into your health savings account (HSA) on a pretax basis. Check with your payroll department before submitting this form; not all employers can arrange for payroll deductions. You must be enrolled in a consumer-directed health plan (CDHP) with an HSA before you can start a payroll deduction.

Form

Extended dependent certification (PEBB) 2020

50-500

Submit this form with your enrollment form if you are enrolling an extended (legal) dependent child.

Form

For Your Benefit (2019-02)

PEBB Program's For Your Benefit newsletter for February 2019.

Newsletter

For Your Benefit (2019-06)

The PEBB Program's For Your Benefit newsletter is your source for updated information about your PEBB benefits.

Newsletter

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