Forms & publications

These are the monthly premiums for PEBB Continuation Coverage subscribers in 2025. These premiums do not include the monthly premium surcharges, if applicable.

Use this form if you are requesting an appeal of a decision.

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

This benefits book describes what is covered under Premera High PPO, including medical services and prescription drugs, 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, submit a claim, and how Medicare works with your plan.

A summary of what the SEBB Premera High PPO plan covers and what it costs.

This benefits book describes what is covered under Premera HMO, including medical services and prescription drugs, 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, submit a claim, and how Medicare works with your plan.

A summary of what the SEBB Premera HMO plan covers and what it costs.

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.

This benefits book describes what is covered under Premera Standard PPO, including medical services and prescription drugs, 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, submit a claim, and how Medicare works with your plan.

A summary of what the SEBB Premera Standard PPO plan covers and what it costs.