Forms & publications

This nondiscrimination statement describes how the PEBB Program and its contracted health plans comply with applicable federal civil rights laws.

Preauthorization requirements for Premera Blue Cross. 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.

Certificate of coverage for Premera Medicare Supplement Plan F for those eligible by age.

Certificate of coverage for Premera Medicare Supplement Plan F, by reason of disability.

Certificate of coverage for Premera Medicare Supplement Plan G for those eligible by age.

Certificate of coverage for Premera Medicare Supplement Plan G for those eligible by disability.

Outline of Medicare Supplement Plan G Coverage. Shows the benefits included in each of the standard Medicare supplement plans.

Complete this form if you do not want to pay your medical premiums with pretax earnings.

Complete this form if you do not want to pay your medical premiums with pretax earnings.

This is the 2025 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.