Medicare Advantage Plan Election Form (form C) 2022

51-0576

Use this form to enroll in Medicare Advantage plans.

Form

Retiree Change Form (form E) 2022

51-0007

Use Form E to make changes to your PEBB retiree insurance coverage.

Form

Retiree Election Form (form A) 2022

51-4031

This is the 2022 Retiree Election Form (form A). Use this form to elect PEBB Retiree insurance coverage. To make changes to your retiree insurance coverage, use the 2022 Retiree Coverage Change Form (form E). Due to the COVID-19 pandemic, the PEBB Program has temporarily changed the deadline to enroll in PEBB retiree insurance coverage when first eligible. To learn more about this exception to the timelines listed in this document, visit HCA's website at hca.wa.gov/coronavirus.

Form