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 WA (formerly Group Health) documents

Certificates of Coverage

Awaiting final approval by the Office of the Insurance Commissioner.

2017

Summaries of benefits and coverage

2017

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.

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

2017

Summaries of benefits and coverage

2017

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.

Uniform Medical Plan documents

Certificates of coverage

2017

Summaries of benefits and coverage

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.