Forms & publications

Employee Monthly Premiums (PEBB) 2024

These premiums apply to PEBB employees in state agencies, higher-education institutions, and community and technical colleges. These premiums do not include the monthly premium surcharges, if applicable to your account.

PEBB Continuation Coverage Premiums 2024

These are the PEBB Continuation Coverage monthly premiums for 2024. These premiums do not include the monthly premium surcharges, if applicable to your account.

Premium Surcharge Attestation Change form (PEBB) 2024

This is the 2024 PEBB Premium Surcharge Attestation Change form. Use this form to report a change that affects your surcharge for tobacco use and/or spouse or state-registered domestic partner coverage.

Premium Surcharge Attestation Change form (SEBB) 2024

This is the 2024 SEBB Premium Surcharge Attestation Change form. Use this form to report a change that affects your surcharge for tobacco use and/or spouse or state-registered domestic partner coverage.

Retiree Monthly Premiums 2024

These are the PEBB retiree premiums for retirees in 2024. These premiums do not include the monthly premium surcharges, if applicable to your account.

School Employee Enrollment Guide 2024

Guidance on SEBB benefits available to school employees and their dependents. This guide includes information on eligibility, enrollment, dependent verification, benefits (medical, dental, vision coverage, life insurance, long-term disability insurance, flexible spending arrangements, the dependent care assistance program, and SmartHealth wellness program), medical plan premiums, medical plans available, premium surcharges, how to change coverage, and how to file an appeal.

Spousal Surcharge Calculator Tool (PEBB) 2024 (xls)

This is the 2024 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions on your enrollment form and are enrolling a spouse or state-registered domestic partner.

Spousal Surcharge Calculator Tool (SEBB) 2024 (xls)

This is the 2024 SEBB Spousal plan calculator form. Use this form if you answered 'YES' to all the questions on your enrollment form and are wanting to enroll a spouse or state-registered domestic partner.