Forms & publications

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Employee monthly premiums 2019

These are the Public Employee Benefits Board (PEBB) Program medical plans offered for 2019. These premiums apply to 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.

Publication

Introduction to PEBB Coverage for Employer Groups 2019 (surcharges)

Explains the PEBB Program for interested employer groups.

Publication

Premium surcharge change form 2019

50-563-2019

This is the 2019 Premium Surcharge Change form. Use this form to report a change that affects your surcharge for tobacco use and/or spouse or registered domestic partner coverage.

Form

Premium surcharge help sheet 2019

50-226-2019

This is the 2019 Premium Surcharge Help Sheet. Use the information on this help sheet to attest on your enrollment form or the Premium Surcharge form whether the premium surcharges apply.

Form

Retiree monthly premiums 2019

These are the Public Employees Benefits Board (PEBB) medical plans offered for retirees in 2019. To the right of each plan are the monthly premiums for an individual employee, employee and spouse,* employee with child(ren), and full family. These premiums do not include the monthly premium surcharges, if applicable to your account.

Publication

School Employees Benefits Board (SEBB) Program Update May 30, 2018

An update on SEB Board resolutions and next steps. On May 30, 2018, the SEB Board passed resolutions on premium surcharges.

Fact sheet

Spousal plan calculator form 2019

50-027-2019

This is the 2019 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions in the 2019 Premium Surcharge Help Sheet and are wanting to enroll a spouse or state-registered domestic partner.

Form

Spousal plan calculator tool 2019 (xls)

This is the 2019 spousal plan calculator. Use this interactive calculator tool to determine if the spousal premium surcharge applies to you if you answered 'YES' to all the questions in the Premium Surcharge Help Sheet and are wanting to enroll a spouse or state-registered domestic partner on your PEBB medical.

Form