Forms & publications

Use this form to enroll in or change your enrollment options for COBRA coverage.

Use this form to enroll in or change your enrollment options for PEBB Continuation Coverage (Unpaid Leave).

These are the PEBB Continuation Coverage monthly premiums for 2024. These premiums do not include the monthly premium surcharges, if applicable to your account.

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

This nondiscrimination statement describes how the PEBB Program and its contracted health plans comply with applicable federal civil rights laws.

This benefits book describes what is covered as a SEBB member under Premera High PPO plan, including medical services and prescription drugs, 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, submit a claim, and how Medicare works with your plan.

A summary of what the SEBB Premera High PPO plan covers and what it costs.

This benefits book describes what is covered as a SEBB member under Premera HMO plan, including medical services and prescription drugs, 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, submit a claim, and how Medicare works with your plan.

A summary of what the SEBB Premera HMO plan covers and what it costs.

Preauthorization requirements for Premera Blue Cross. 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.