Forms & publications

This chart briefly compares the per-visit costs of some in-network benefits for PEBB Medicare plans. Some copays and coinsurance do not apply until after you have paid your annual deductible. Call the plans for more information on specific benefits, including preauthorization requirements and exclusions.

This document outlines costs and coverage details for PEBB Medicare plans. If anything in this document conflicts with the plan’s benefits book, the benefits book takes precedence.

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.

Preauthorization requirements for Davis Vision. 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.

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.

Subscribers must complete 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.

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.

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.

This document outlines costs and coverage details for PEBB dental plans. If anything in this document conflicts with the plan’s benefits book, the benefits book takes precedence.

PEBB Electronic Debit Service (EDS) is only available to retirees and continuation coverage subscribers. Electronic service allows PEBB subscribers to have monthly payments automatically taken from a checking or savings account.