Forms & publications

The 2026 SEBB Premium Surcharge Attestation Change form. Use this form to report a change that affects your surcharge for tobacco use and/or spouse or state-registered domestic partner coverage.

This is the 2025 Retiree Enrollment Guide. It contains information you need about enrollment, eligibility, benefits, monthly premiums, and the plans available to retirees.

This is the 2026 Retiree Enrollment Guide. It contains information you need about enrollment, eligibility, benefits, monthly premiums, and the plans available to retirees.

These are the PEBB retiree premiums for retirees in 2025. These premiums do not include the monthly premium surcharges, if applicable to your account.

These are the PEBB retiree monthly medical plan premiums for retirees in 2026. These premiums do not include the monthly premium surcharges, if applicable to your account. You are still responsible for paying the Medicare Part B premium. Medicare Part D premium is included in the PEBB Medicare Advantage with Part D plans.

Use this form if you are requesting an appeal of a decision.

School board members use this form to enroll in your SEBB insurance coverage.

School board members use this form to enroll in your SEBB insurance coverage.

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 high deductible health plan with an HSA before you can start a payroll deduction.

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 high deductible health plan with an HSA before you can start a payroll deduction.