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.

Publication

Premera 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.

Publication

Premera 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.

Publication

Premera 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.

Publication

Premera 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.

Publication

Premium payment plan election/change (SEBB) 2020

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

Form

Premium payment plan election/change form (PEBB) 2020

Use this form to pay for your premiums after taxes.

Form

Premium surcharge attestation change form (PEBB) 2020

50-563

This 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.

Form

Premium surcharge attestation change form (SEBB) 2020

20-0041

This 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.

Form

Premium surcharge attestation help sheet (PEBB) 2020

50-226

This 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.

Form

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