Certification of a Child with a Disability (PEBB)
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.
Forms & publications
Extended Dependent Certification (PEBB)
Submit this form with your enrollment form if you are enrolling an extended (legal) dependent child.
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.
MetLife Cancellation of Supplemental Life Insurance - PEBB Employee
Use this form to notify MetLife that you wish to cancel your Supplemental Life Insurance and/or Supplemental Accidental Death & Dismemberment (AD&D) Insurance. For employees only: Employee Basic Life Insurance ($35,000) and Employee Basic AD&D Insurance ($5,000) is not affected by this form. It is provided by your employer at no cost to you. You cannot cancel your Employee Supplemental Life Insurance and keep Dependent Life Insurance.
PEBB Employee Request for Review/Notice of Appeal
Use this form if you are requesting an appeal of a decision.
Premium Payment Election/Change form (PEBB)
Complete this form if you do not want to pay your medical premiums with pretax earnings.
UMP (ArrayRx) Authorization for Release of Information for non-Medicare PEBB and SEBB members
This form directs ArrayRx to communicate with you about your personal health information at the address you select. This form does not apply to your health care provider. You must give your provider separate, specific instruction about what health information they may share and with whom.
UMP (ArrayRx) disclosure directive form
This form directs ArrayRx to communicate with you about your personal health information at the address you select.
UMP (ArrayRx) Multiple prescription drug coverage inquiry form (coordination of benefits [COB])
This form is for notifying ArrayRx that you have prescription drug coverage in addition to Uniform Medical Plan (UMP).
UMP (ArrayRx) Prescription Drug Claim Form
This is an ArrayRx claim form for reimbursement for prescription drugs for Uniform Medical Plan (UMP) members. Members might use this form if they purchased drugs at nonnetwork pharmacies or have other prescription coverage that pays first and UMP is secondary. Members might also use this form if they fail to show their ID at a network pharmacy or get a prescription from a mail-order or internet pharmacy other than Costco Mail-Order Pharmacy or Postal Prescription Services.