Forms & publications

This benefits book describes what is covered as a SEBB member under Premera Standard 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 Standard PPO plan covers and what it costs.

Certificate of coverage for Premera Medicare Supplement Plan G for those eligible by age.

Certificate of coverage for Premera Medicare Supplement Plan F, by reason of disability.

Use this form to enroll in Medicare Supplement Plan G administered by Premera.

Certificate of coverage for Premera Medicare Supplement Plan G for those eligible by age.

Certificate of coverage for Premera Medicare Supplement Plan G for those eligible by disability.

Outline of Medicare Supplement Plan G Coverage. Shows the benefits included in each of the standard Medicare supplement plans.

Complete this form if you do not want to pay your medical premiums with pretax earnings.

Complete this form if you do not want to pay your medical premiums with pretax earnings.