Benefits and coverage by plan
Get plan benefits booklets, find out what is covered, and your costs for care.
On this page
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' benefits booklet.
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.
- Evidence of Coverage (EOC)
-
Non-Medicare retiree plans
2023
2022
Medicare retiree plan (COBRA only)
2023
2022
- Summary of Benefits and Coverage
-
Non-Medicare retiree plans
2023
2022
- Preauthorization criteria
-
Kaiser Permanente NW preauthorization requirements
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.
Kaiser Permanente WA documents
Kaiser Foundation Health Plan of Washington.
- Evidence of Coverage (EOC)
-
Non-Medicare Retirees
2023
- Kaiser Permanente WA Classic (2023)
- Kaiser Permanente WA CDHP (2023)
- Kaiser Permanente WA SoundChoice (2023)
- Kaiser Permanente WA Value (2023)
2022
- Kaiser Permanente WA Classic (2022)
- Kaiser Permanente WA CDHP (2022)
- Kaiser Permanente WA SoundChoice (2022)
- Kaiser Permanente WA Value (2022)
Medicare Retirees
2023
2022
- Summary of Benefits and Coverage
-
Non-Medicare retiree plans
2023
- Kaiser Permanente WA Classic (2023)
- Kaiser Permanente WA CDHP (2023)
- Kaiser Permanente WA SoundChoice (2023)
- Kaiser Permanente WA Value (2023)
2022
- Preauthorization criteria
-
Kaiser Permanente WA preauthorization requirements
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.
Premera Blue Cross documents
Outline of coverage
Medicare retiree plan
Uniform Medical Plan documents
- Certificate of Coverage (COC)
-
Non-Medicare retiree plans
2023
- UMP Classic (2023)
- UMP Select (2023)
- UMP Consumer-Directed Health Plan (UMP CDHP) (2023)
- UMP Plus-Puget Sound High Value Network (PSHVN) (2023)
- UMP Plus-UW Medicine Accountable Care Network (UW Medicine ACN) (2023)
Medicare retiree plan (COBRA only)
2023
Non-Medicare retiree plans
2022
- UMP Classic (2022)
- UMP Select (2022)
- UMP Consumer-Directed Health Plan (UMP CDHP) (2022)
- UMP Plus–Puget Sound High Value Network (PSHVN) (2022)
- UMP Plus–UW Medicine Accountable Care Network (UW Medicine ACN) (2022)
Medicare retiree plan (COBRA only)
2022
- Summary of Benefits and Coverage
-
Non-Medicare retiree plans
2023
- UMP Classic (2023)
- UMP Select (2023)
- UMP Consumer-Directed Health Plan (CDHP) (2023)
- UMP Plus–Puget Sound High Value Network (PSHVN) (2023)
- UMP Plus–UW Medicine Accountable Care Network (UW Medicine ACN) (2023)
2022
- UMP Classic (2022)
- UMP Select (2022)
- UMP Consumer-Directed Health Plan (CDHP) (2022)
- UMP Plus–Puget Sound High Value Network (PSHVN) (2022)
- UMP Plus–UW Medicine Accountable Care Network (UW Medicine ACN) (2022)
Medicare (COBRA only)
2023
2022
- Preauthorization criteria
-
Regence preauthorization requirements (for UMP plans)
- Document 1: Guidelines, inpatient admissions, radiology, sleep, physical medicine, lab, maternity medicine, and genetic testing
- Document 2: Substance use disorder, mental health, DME, surgery and transplants
- Medications covered under medical
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.
Washington State Rx Services preauthorization requirements (for pharmacy)
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.