Forms & publications

This booklet gives you the details about your Medicare health care coverage from your UnitedHealthcare PEBB Complete (MAPD). It explains how to get coverage for the health care services you need. This is an important legal document.

This document briefly compares the per-visit costs of some benefits for SEBB vision plans. The figures listed in the comparison show what you pay for in-network services, with the amount up to which you would be reimbursed for out-of-network services in parentheses. If anything in these charts conflicts with the vision plan’s Certificate of Coverage (COC), the COC takes precedence. For information on specific benefits and exclusions, refer to the plan’s COC or contact the plan.

Preauthorization for UMP plans pharmacy benefits (administered by Washington State Rx Services). 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.

Preauthorization for UMP plans pharmacy benefits (administered by Washington State Rx Services). 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.

Preauthorization for UMP plans pharmacy benefits (administered by Washington State Rx Services). 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.

Preauthorization for UMP plans pharmacy benefits (administered by Washington State Rx Services). 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 benefits book describes what is covered under Willamette Dental, including dental services, as well as specific services not covered by the plan finding preferred providers and how much you’ll pay, including deductibles, coinsurance, and copays. It also includes how to request an appeal and how to submit a claim.

Preauthorization requirements for Willamette Dental Group. 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 benefits book describes what is covered under Willamette Dental, including dental services, as well as specific services not covered by the plan finding preferred providers and how much you’ll pay, including deductibles, coinsurance, and copays. It also includes how to request an appeal and how to submit a claim.

Preauthorization requirements for Willamette Dental Group. 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.