2019 PEBB open enrollment has begun. You have until November 30, 2018 to make changes to your coverage.

Benefits and coverage by plan

What is a certificate of coverage (COC)?

The certificates of coverage (COCs), also called benefits booklets, are produced by the health plans to provide detailed information about plan benefits and what is and is not covered.

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 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 benefits comparison tool, or the plans' certificates of coverage.

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, with plans offered in Clark and Cowlitz counties in Washington and select counties in Oregon.

Certificates of Coverage

2018

Summaries of Benefits and Coverage

2018

2019

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

Certificates of Coverage

The 2018 Kaiser Permanente WA certificates of coverage have been revised to address and clarify a bariatric surgery benefit. The corrected booklet was updated November 7, 2017.

2018

2019

Summaries of Benefits and Coverage

2018

2019

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.

Uniform Medical Plan documents

Certificates of Coverage

2018

2019

Summaries of Benefits and Coverage

2018

2019

Preauthorization criteria

Regence preauthorization requirements (for UMP plans)

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)

Washington State Rx Services 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.