Forms & publications

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Delta Dental (DeltaCare and Uniform Dental Plan) (PEBB) preauthorization requirements

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.

Publication

Delta Dental (DeltaCare and Uniform Dental Plan) (SEBB) preauthorization requirements

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.

Publication

DeltaCare (PEBB) Certificate of Coverage (COC) 2019

This benefits book describes what is covered under DeltaCare, 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.

Publication

DeltaCare (PEBB) Certificate of Coverage (COC) 2020

This benefits book describes what is covered under DeltaCare, 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.

Publication

DeltaCare (SEBB) Certificate of Coverage (COC) 2020

This benefits book describes what is covered under DeltaCare, 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.

Publication

Directions to Cherry Street Plaza

Fact sheet

Electronic debit service (EDS) agreement 2020

Electronic Debit Service (EDS) is only available to continuously enrolled self-pay PEBB subscribers. Electronic service allows PEBB subscribers to have monthly payments automatically taken from a checking or savings account.

Form

Electronic debit service agreement

42-450

Electronic Debit Service (EDS) is only available to continuously enrolled self-pay PEBB subscribers. Electronic service allows PEBB subscribers to have monthly payments automatically taken from a checking or savings account.

Form

Employee enrollment guide 2019

50-100

Guidance on PEBB Program benefits available to eligible employees and their dependents.

Publication

Employee enrollment/change for medical groups only (PEBB) 2020

52-030

Use this form to enroll in or make changes to PEBB Program benefits for you and your dependents if your employer offers PEBB Program medical coverage only.

Form

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