Forms & publications

This is the 2024 Retiree Coverage Election Form (form A). Use this form to enroll in PEBB Retiree insurance coverage. To make changes to your retiree insurance coverage, use the 2024 Retiree Coverage Change Form (form E).

This is the 2024 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 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.

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.

Guidance on SEBB benefits available to school employees and their dependents. This guide includes information on eligibility, enrollment, dependent verification, benefits (medical, dental, vision coverage, life insurance, long-term disability insurance, flexible spending arrangements, the dependent care assistance program, and SmartHealth wellness program), medical plan premiums, medical plans available, premium surcharges, how to change coverage, and how to file an appeal.

This shows the monthly medical premiums, annual medical deductibles, and out-of-pocket maximums for school employees in 2024.

Use this form if you disagree with a decision made by your employer or the SEBB Program.

A fact sheet with information on how Apple Health works for SEBB Program subscribers.