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Completing the retiree forms

Find out which forms you need and how to complete them. 

Need help completing 2020 Retiree Coverage Election Form (form A)?

Use the step-by-step tutorial

What steps should I take?

Based on the action you are taking and the plan you choose, you will need to complete at least one form to:

  • Enroll in PEBB retiree insurance coverage for the first time, or
  • Make changes to your existing PEBB enrollment if you're within 60 days of a qualifying event (like the birth of a child, marriage, or divorce).

To begin, find the action you are taking

Use the Retiree Election Form (form A)

Step 1: View medical plans available by county to find the plans available to you based on your home address. Not sure which plan to choose? Visit our Compare medical plans webpage to explore your options.

Step 2: Find your medical plan choice under Which forms should I complete? on this page. Complete the forms listed there in addition to Form A. Include all eligible dependents you wish to enroll.

Step 3: Submit the forms to the PEBB Program. We must receive your forms and any other requested documents, such as proof of dependent eligibility, by the deadline.

Use the Retiree Change Form (form E)

Step 1: Fill out the Retiree Change Form (form E).

Step 2: If you are changing medical plans, view medical plans available by county to find the plans available to you based on your home address. Not sure which plan to choose? Visit our Compare medical plans webpage to explore your options.

Step 3: Find your medical plan choice under Which forms should I complete? on this page. Complete the forms listed there in addition to Form A. Include all eligible dependents you wish to enroll or continue covering.

Also complete a Medicare Advantage Plan Disenrollment Form (form D) if you or a covered dependent are:

  • Enrolled in a Medicare Advantage plan and changing to a plan that is not a Medicare Advantage plan, or
  • Removing a Medicare eligible dependent.

Step 4: Submit the forms and any other requested documents, such as proof of dependent eligibility, to the PEBB Program by the deadline.

Use the Retiree Election Form (form A)

Step 1: Complete all sections marked required in the Retiree Election Form (form A), including:

  • Section 1 (Subscriber Information and Enrollment Election),
  • Section 7 (Signature), and if applicable,
  • Section 5 (Retiree Term Life Insurance Election) and Section 6 (Payment Authorization).

Note: When deferring you must maintain continuous enrollment in qualifying medical coverage if you wish to enroll in a PEBB retiree health plan in the future.

Step 2: Submit the form to the PEBB Program. The PEBB Program must receive it by the deadline.

Use the Retiree Change Form (form E)

Step 1: Complete all sections marked "Required" in the Retiree Change Form (form E), including:

  • Section 1 (Subscriber Information and Enrollment Change), and
  • Section 8 (Signature).

Step 2: If you or a covered dependent are cancelling (terminating) enrollment in a Medicare Advantage plan, also complete a Medicare Advantage Plan Disenrollment Form (form D).

Step 3: Submit the forms to the PEBB Program. Your PEBB retiree health plan coverage will end on the last day of the month in which we receive all of your forms. If the forms arrive on the first day of the month, coverage will end on the previous day.

Which forms should I complete?

Find the action you are taking, then find your plan and submit the forms listed.

To enroll in these plans or defer:

Plan name Use
  • Kaiser Permanente NW Classic* or CDHP*
  • Kaiser Permanente WA Classic, CDHP, Original Medicare, SoundChoice, or Value
  • Uniform Medical Plan (UMP) Classic, Select, CDHP, UMP Plus—PSHVN, or UMP Plus—UW Medicine ACN
Form A only

To enroll in these plans:

Plan name Use
  • Kaiser Permanente NW Senior Advantage
  • Kaiser Permanente WA Medicare Advantage
  • UnitedHealthcare PEBB Balance or UnitedHealthcare PEBB Complete
Forms A and C
  • Medicare Supplement Plan G, administered by Premera Blue Cross
Forms A and B

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

To cancel (terminate), remove a dependent, or defer from these plans (after enrolling):

Plan name Use
  • Kaiser Permanente NW Senior Advantage
  • Kaiser Permanente WA Medicare Advantage
  • UnitedHealthcare PEBB Balance or UnitedHealthcare PEBB Complete
Forms E and D

To make changes or switch to these plans, cancel (terminate), or defer (after enrolling):

Plan name Use
  • Kaiser Permanente NW* Classic or CDHP
  • Kaiser Permanente NW Senior Advantage
  • Kaiser Permanente WA Classic, CDHP, Original Medicare, SoundChoice, or Value
  • Kaiser Permanente WA Medicare Advantage
  • Uniform Medical Plan Classic, UMP Select, UMP CDHP, UMP Plus—Puget Sound High Value Network, or UMP Plus—UW ACN

Note: Also include Form D if switching out of Kaiser Permanente NW Senior Advantage, Kaiser Permanente WA Medicare, UnitedHealthcare PEBB Balance or UnitedHealthcare PEBB Complete.

Form E only

To make changes or switch to these plans:

Plan name Use
  • Kaiser Permanente NW Senior Advantage
  • Kaiser Permanente WA Medicare Advantage
  • UnitedHealthcare PEBB Balance or UnitedHealthcare PEBB Complete

Note: Also include Form D if switching out of Kaiser Permanente NW Senior Advantage, Kaiser Permanente WA Medicare, UnitedHealthcare PEBB Balance or UnitedHealthcare PEBB Complete.

Forms E and C
  • Premera Blue Cross Medicare Supplement Plan G

Note: Also include Form D if switching out of Kaiser Permanente NW Senior Advantage, Kaiser Permanente WA Medicare, UnitedHealthcare PEBB Balance or UnitedHealthcare PEBB Complete.

Forms E and B

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

Additional forms you may need

If enrolling a: Complete this form:
Nonqualified tax dependent Declaration of tax status
Dependent child with a disability Certification of a child with a disability
Extended (legal) dependent child Extended dependent certification

Where do I send my forms?

Submit the forms to:

Washington State Health Care Authority
PEBB Program
PO Box 42684
Olympia, WA 98504-2684

If you're sending payment with your forms, please enclose your check or money order payable to Health Care Authority and mail to:

Washington State Health Care Authority
PO Box 42691
Olympia, WA 98504-2695

Things to remember

  • If you or any covered dependents haven’t sent us a copy of your Medicare cards, send it along with your forms. Write your full name and the last four digits of your Social Security number on the copy of your card.
  • If you are not enrolled in Medicare Part A and Part B, you must provide copies of documents that prove eligibility of any dependents you wish to enroll.
  • If you’re adding a state-registered domestic partner or a state-registered domestic partner’s child to your coverage, you must also complete and submit the Declaration of Tax Status. Proof of their eligibility is also required. 
  • If you’re adding a state-registered domestic partner to your coverage and completing Form C, fill out the “spouse” sections of the form for your partner.
  • Please use dark ink to complete the forms.

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