Bookmark & Share- If you are not on Medicare and want to enroll a dependent, you must provide proof of eligibility for any dependents you include on your enrollment form. See the list of acceptable documents.
- If you're adding a registered domestic partner to your coverage, you must also complete and submit the Declaration of Tax Status form.
- If you're adding a registered domestic partner to your coverage and completing Form C, he or she should fill out the "spouse" sections.
New Enrollment
Step 1:
Find the medical plans available to you. You also have three dental plans to choose from, as long as you are also enrolled in medical coverage and continue dental coverage for at least two years. (You can change dental plans during open enrollment.)
Step 2:
Locate your plan choice in the columns below and complete the appropriate form(s).
Step 3:
Be sure to include all eligible family members you wish to enroll.
Changing Enrollment
Step 1:
If you are changing medical or dental plans or adding family members to your coverage, fill out Form A.
Step 2:
If you are changing medical plans, find the medical plans available to you.
Step 3:
Locate your plan choice in the columns below and complete the appropriate form(s).
If you are currently enrolled in a Medicare Advantage plan and change to a plan that is not another Medicare Advantage plan, you will also need to complete Form D.
Note for Medicare enrollees: If you are selecting a plan that offers both a standard managed-care plan and a Medicare Advantage plan in your county, you will be required to enroll in the Medicare Advantage plan.
| Complete Form A to enroll in or make changes to a plan listed here | Complete Form A and Form B to enroll in or make changes to a plan listed here | Complete Form A and Form C to enroll in or make changes to a plan listed here | Use Form D to disenroll from a plan listed here |
Group Health CDHP, Classic, Medicare Plan or Value Kaiser Permanente Classic or CDHP Uniform Medical Plan Classic or UMP CDHP, administered by Regence BlueShield |
Medicare Supplement Plan F, administered by Premera Blue Cross | Group Health Medicare Plan (Medicare Advantage*) (Classic and Value plans not available to Medicare retirees in 2012) Kaiser Permanente Senior Advantage Classic |
Group Health Medicare Advantage Kaiser Permanente Senior Advantage Classic |
*If a Group Health subscriber is enrolled in Medicare Part A and Part B but covers a family member not eligible for Medicare, the family member must enroll in a Group Health Classic or Value plan. The Medicare enrollees will be enrolled in Medicare Advantage or Medicare coordination plan.
Mail Your Form(s)
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 have questions about the enrollment process, please call the PEBB Program at 1-800-200-1004.
