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 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. The COC is 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 PEBB'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, with plans offered in Clark and Cowlitz counties in WA, and the Portland, OR area.
Certificates of coverage
Non-Medicare retiree plans
2018
Medicare retiree plan
2018
Summaries of benefits and coverage
Non-Medicare retiree plans
2018
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 (formerly Group Health) 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.
Non-Medicare retiree plans
2018
- Kaiser Permanente WA (formerly Group Health) Classic (2018)
- Kaiser Permanente WA (formerly Group Health) CDHP (2018)
- Kaiser Permanente WA (formerly Group Health) SoundChoice (2018)
- Kaiser Permanente WA (formerly Group Health) Value (2018)
Medicare retiree plans
2018
- Kaiser Permanente WA (formerly Group Health) Original Medicare (2018)
- Kaiser Permanente WA (formerly Group Health) Medicare Advantage (2018)
Summaries of benefits and coverage
Non-Medicare retiree plans
2018
- Kaiser Permanente WA (formerly Group Health) Classic (2018)
- Kaiser Permanente WA (formerly Group Health) CDHP - Family (2018)
- Kaiser Permanente WA (formerly Group Health) CDHP - Individual (2018)
- Kaiser Permanente WA (formerly Group Health) SoundChoice (2018)
- Kaiser Permanente WA (formerly Group Health) Value (2018)
Medicare retiree plans
2018
Preauthorization criteria
Kaiser Permanente WA (formerly Group Health) 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
Certificate of coverage
Outline of coverage
Summaries of benefits and coverage are not available for Medicare supplement plans. For PEBB Program Medicare plan summaries, see the medical benefits comparison tool.
Uniform Medical Plan documents
Certificates of coverage
Non-Medicare retiree plans
2018
- UMP Classic (2018)
- UMP Consumer-Directed Health Plan (UMP CDHP) (2018)
- UMP Plus—Puget Sound High Value Network (PSHVN) (2018)
- UMP Plus—UW Medicine Accountable Care Network (UW Medicine ACN) (2018)
Medicare retiree plan
2018
- UMP Classic (2018)
Summaries of benefits and coverage
Non-Medicare retiree plans
2018
- UMP Classic (2018)
- UMP CDHP (2018)
- UMP Plus–Puget Sound High Value Network (2018)
- UMP Plus–UW Medicine Accountable Care Network (2018)
Medicare retiree plan
2018
- UMP Classic (2018)
Preauthorization criteria
Regence preauthorization requirements (for UMP plans)
- UMP preauthorization guidelines
- Allied Health and durable medical equipment
- Chemical dependency and mental health
- Genetic testing
- Inpatient admissions
- Laboratory, maternity, and medicine
- Medications covered under medical
- Radiology
- Surgery
- Transplants, ventricular assist devices, and utilization management
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.
