Benefits and coverage by plan

Get plan benefits booklets, find out what is covered, and your costs for care.

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 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.

Group Health documents

Certificates of Coverage

Awaiting final approval by the Office of the Insurance Commissioner.

Non-Medicare Retirees

2017

Summaries of benefits and coverage

Non-Medicare retiree plans

2017

Preauthorization criteria

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.

Kaiser Permanente documents

Certificates of coverage

Non-Medicare retiree plans

2017

Medicare retiree plan (COBRA only)

2017

Summaries of benefits and coverage

Non-Medicare retiree plans

2017

Preauthorization criteria

Kaiser Permanente 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

Medicare retiree plan

2017

Uniform Medical Plan documents

Certificates of coverage

Non-Medicare retiree plans

2017

Medicare retiree plan (COBRA only)

2017

Summaries of benefits and coverage

Non-Medicare retiree plans

2017

Medicare retiree plan (COBRA only)

2017

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.