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Premera Peak Care EPO (SEBB) Summary of Benefits and Coverage (SBC) 2021
A summary of what the SEBB Premera Peak Care EPO plan covers and what it costs.
PublicationPremera Standard PPO (SEBB) Certificate of Coverage (COC) 2020
This benefits book describes what is covered as a SEBB member under Premera Standard PPO plan, 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.
PublicationPremera Standard PPO (SEBB) Certificate of Coverage (COC) 2021
This benefits book describes what is covered as a SEBB member under Premera Standard PPO plan, 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.
PublicationPremera Standard PPO (SEBB) Summary of Benefits and Coverage (SBC) 2020
A summary of what the SEBB Premera Standard PPO plan covers and what it costs.
PublicationPremera Standard PPO (SEBB) Summary of Benefits and Coverage (SBC) 2021
A summary of what the SEBB Premera Standard PPO plan covers and what it costs.
PublicationPremium payment plan election/change (SEBB) 2020
Complete this form if you do not want to pay your medical premiums with pretax earnings.
FormPremium payment plan election/change form (PEBB) 2020
Use this form to pay for your premiums after taxes.
FormPremium surcharge attestation change form (PEBB) 2020
50-563This is the 2020 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.
FormPremium surcharge attestation change form (SEBB) 2020
20-0041This is the 2020 SEBB 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.
FormPremium surcharge attestation help sheet (PEBB) 2020
50-226This is the 2020 Premium Surcharge Attestation Help Sheet. Use the information on this help sheet to attest on your enrollment form or the Premium Surcharge form whether the premium surcharges for tobacco use or spouse/state-registered domestic partner apply.
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