Benefits and coverage by plan

What is a benefits booklet?

The benefits booklets, also called an evidence of coverage (EOC) or a certificate of coverage (COC), are produced by the health plans to provide detailed information about plan benefits and what is and is not covered. They are the primary source of coverage provisions offered under the plan.

What is a summary of benefits and coverage (SBC)?

Summaries of benefits and coverage (SBCs) are required under the federal Affordable Care Act to help members understand plan benefits and medical terms. SBCs are not available for Medicare Advantage plans and Medicare supplement plans. For PEBB Program Medicare plan summaries, use the medical benefit comparison tool.

SBCs help you compare things like:

• Whether there are services a plan doesn't cover
• What isn't included in a plan's out-of-pocket limit
• Whether you need a referral to see a specialist

The PEBB Program and/or medical plans provide SBCs, or notice of how to get one, at different times throughout the year (like when you apply for coverage, renew your plan, or request an SBC). SBCs are available (upon request) in English, Spanish, Tagalog, Chinese, and Navajo.

SBCs don't replace the PEBB Program's medical benefit comparison tool, or the plans' certificates of coverage.

SBCs are not available for Medicare Advantage plans and Medicare supplement plans. For PEBB Medicare plan summaries, use the medical benefit comparison tool.

What are preauthorization criteria?

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. Preauthorization is not a guarantee, however, that your plan will pay for those services, supplies or drugs.

The criteria included in the preauthorization requirements below state how a plan determines when a service, supply, or drug is medically necessary and will be covered.

Kaiser Permanente NW documents

Kaiser Foundation Health Plan of the Northwest offers plans in Clark and Cowlitz counties in Washington, and select counties in Oregon.

Kaiser Permanente WA documents

Kaiser Foundation Health Plan of Washington.

Premera Blue Cross documents

Outline of coverage

Medicare retiree plan

• Medicare Supplement Plan G (Summary) (2022)

Uniform Medical Plan documents

UnitedHealthcare documents (COBRA only)

Evidence of Coverage

• UnitedHealthcare PEBB Balance (2022)
• UnitedHealthcare PEBB Complete (2022)