Completing the retiree forms

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

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Follow the steps below to enroll in PEBB retiree 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).

New enrollment or enrolling after deferral

Step 1:  Visit compare medical plans to compare retiree plan choices and make sure you live in the plan's service area.

Step 2:  Depending on your plan choice, complete the appropriate form(s) listed below under Form(s) to complete.

Step 3:  Be sure to include all eligible family members you wish to enroll.

Enrollment changes

Step 1:  If you're changing medical or dental plans, or adding family members to your coverage, fill out Form A, plus additional forms, if required.

Step 2:  If you're changing medical plans, visit compare medical plans to compare retiree plan choices and make sure you live in the plan's service area.

Step 3:  Depending on your plan choice, complete the appropriate form(s) listed below under Form(s) to complete. If you are enrolled in a Medicare Advantage plan and change to a plan that is not a Medicare Advantage plan, you will also need to complete Form D.

Deferring or cancelling enrollment in PEBB benefits

If you're deferring or cancelling enrollment in your PEBB benefits, fill out all sections marked required in the Retiree Coverage Election/Change Form (Form A) including:

  • Section 1 (subscriber information)
  • Section 9 (signature)

and if applicable

  • Section 7 (Retiree Term Life election)

and

  • Section 8 (Payment authorization)

Mail the completed for to the PEBB Program. The PEBB Program must receive this form no later than 60 days after your employer-paid coverage, COBRA coverage, or continuation coverage ends.

Forms to complete

Depending on your plan choice, complete the appropriate form(s) listed below to enroll in or make changes to a plan.

Form A

Use Retiree Coverage Election/Change Form (Form A) for the following plans:

  • Kaiser Permanente WA (formerly Group Health) Classic, CDHP, Medicare Plan (Original Medicare), or Value
  • Kaiser Permanente NW* Classic or CDHP

*Kaiser Foundation Health Plan of the Northwest, with plans offered in Clark and Cowlitz counties in WA, and the Portland, OR area.

  • Uniform Medical Plan Classic or UMP CDHP

Forms A and B

Use Retiree Coverage Election Form (Form A) and Medicare Supplement Plan F form (Form B) for the following plan:

  • Medicare Supplement Plan F, administered by Premera Blue Cross

Forms A and C

Use Retiree Coverage Election Form (Form A) and Medicare Advantage Plan Election Form (Form C) for the following plans:

  • Kaiser Permanente WA (formerly Group Health) Medicare Plan (Medicare Advantage)
  • Kaiser Permanente NW Senior Advantage

Forms A and D

Use Retiree Coverage Election Form (Form A) and  Medicare Advantage Plan Disenrollment Form (Form D) to cancel the following plans:

  • Kaiser Permanente WA (formerly Group Health) Medicare Advantage
  • Kaiser Permanente NW Senior Advantage

Mail your forms

Complete, sign, and date the form(s) and mail them to:

Washington State Health Care Authority
PEBB Program
P.O. Box 42684
Olympia, WA 98504-2684

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

Washington State Health Care Authority
P.O. Box 42695
Olympia, WA 98504-2695

Things to remember

  • If you or any covered dependents haven’t sent us a copy of your Medicare card(s), send it along with your form(s).
  • 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 form. Proof of their eligibility is also required. A list of acceptable documents is on the next page.
  • 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 black ink to complete the form(s).