Forms & publications

A summary of what the PEBB Kaiser Permanente WA Value plan covers and what it costs.

This benefits book describes what is covered as a SEBB member under Kaiser Permanente WA Summit PPO 2, 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.

This is the Long-term Disability (LTD) Certificate of Coverage (COC) for Public employees in PEBB benefits. It includes information on eligibility, enrollment, exclusions, and premiums.

This is the Long-term Disability (LTD) Certificate of Coverage (COC) for school employees in SEBB benefits. It includes information on eligibility, enrollment, exclusions, and premiums.

The chart briefly compares the medical deductibles and per-visit out-of-pocket costs of some in-network benefits for PEBB medical plans. Copays and coinsurances may apply; some copays and coinsurance do not apply until after you have paid your annual deductibles. Call the plans directly for more information on specific benefits, including preauthorization requirements and exclusions. If anything in these charts conflicts with the plan’s benefits book, the benefits book takes precedence and prevails.

The chart briefly compares the medical deductibles and per-visit out-of-pocket costs of some in-network benefits for SEBB medical plans. Copays and coinsurances may apply; some copays and coinsurance do not apply until after you have paid your annual deductibles. Call the plans directly for more information on specific benefits, including preauthorization requirements and exclusions. If anything in these charts conflicts with the plan’s benefits book, the benefits book takes precedence.

All school employees are offered a selection of plans based on their county of residence or the county where their employment location is based. Some school employees may have more plan options if they work in a district that crosses county lines (see the school districts by county list starting on page 3 for more information). Be sure to call the medical plans you are interested in to ask about provider availability.

Use this form to disenroll from a Medicare Advantage plan.

This chart briefly compares the per-visit costs of some in-network benefits for PEBB Medicare medical plans. Some copays and coinsurance do not apply until after you have paid your annual deductible. Call the plans directly for more information on specific benefits, including preauthorization requirements and exclusions.

Use this form to name the persons or entities you want to receive your life insurance proceeds after your death. Return this form to MetLife.