Forms & publications

School Employees and SEBB Continuation Coverage must complete and submit this form with their enrollment form when enrolling an individual on their SEBB Program coverage who does not qualify as their dependent for federal tax purposes.

Preauthorization requirements for DeltaCare and Uniform Dental Plan (administered by Delta Dental of Washington). 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. 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.

Preauthorization requirements for DeltaCare and Uniform Dental Plan (administered by Delta Dental of Washington). 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. 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.

This benefits book describes what is covered under DeltaCare, including dental services as well as specific services not covered by the plan, finding preferred providers and how much you’ll pay, including deductibles, coinsurance, and copays. It also includes how to request an appeal and how to submit a claim.

This benefits book describes what is covered under DeltaCare, including dental services as well as specific services not covered by the plan, finding preferred providers and how much you’ll pay, including deductibles, coinsurance, and copays. It also includes how to request an appeal and how to submit a claim.

This chart briefly compares the per-visit costs of some in-network benefits for PEBB dental plans. Some copays and coinsurance do not apply until after you have paid your annual deductible. For information on specific benefits and exclusions, refer to the dental plan’s certificate of coverage or contact the plan.

This chart briefly compares the per-visit costs of some in-network benefits for SEBB dental plans. Some copays and coinsurance do not apply until after you have paid your annual deductible. For information on specific benefits and exclusions, refer to the dental plan’s certificate of coverage or contact the plan.

PEBB Electronic Debit Service (EDS) is only available to retirees and continuation coverage subscribers. Electronic service allows PEBB subscribers to have monthly payments automatically taken from a checking or savings account.

Electronic Debit Service (EDS) is only available to continuation coverage subscribers. Electronic service allows SEBB subscribers to have monthly payments automatically taken from a checking or savings account.

Use this form to have your employer withhold money from your paychecks and deposit it into your health savings account (HSA) on a pretax basis. Check with your payroll department before submitting this form; not all employers can arrange for payroll deductions. You must be enrolled in a consumer-directed health plan (CDHP) with an HSA before you can start a payroll deduction.