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Find the Enrollment Form(s) You Need

If you and your dependents are not entitled to Medicare, or if you're changing dental plans you will only need to complete Form A (499.6 KB).

However, if you or your dependents are entitled to Medicare Parts A and B, the following steps will identify the required enrollment form(s) to complete. Please note if you are entitled to Medicare, you must enroll in both Parts A and B of Medicare to continue PEBB coverage.

Step 1:

Find the medical plans available to you. You 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 do not have to enroll in the same dental plan every year.)

Step 2:

If you're changing dental plans, or adding family members to your coverage, fill out Form A (499.6 KB). Once you have selected a medical plan, locate that plan in the columns below and complete the appropriate form(s).

Complete Form A only	Complete Form A and Form B	Complete Form A and Form C
Aetna Public Employees Plan	Medicare Supplement Plan E, administered by Premera Blue Cross	Group Health Medicare Advantage Classic
Group Health Classic	Medicare Supplement Plan J, administered by Premera Blue Cross	Group Health Medicare Advantage Value
Group Health Value		Kaiser Permanente Senior Advantage Classic
Kaiser Permanente Classic		Kaiser Permanente Senior Advantage Value
Kaiser Permanente Value		Secure Horizons Classic
Uniform Medical Plan		Secure Horizons Value
	Please note: If you're adding a qualified domestic partner to your coverage and completing Form C, qualified domestic partners need to use the "spouse" sections.

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.

If you are currently enrolled in a Medicare Advantage plan and are changing to a managed-care plan, UMP, or Medicare supplement plan; or choose to defer coverage, you will also need to complete Form D (302.2 KB). If you have not already provided a copy of your Medicare card(s) to PEBB, please enclose a copy with your enrollment forms.

Step 3:

If you are adding a spouse or qualified qualified domestic partner, please be sure to complete, sign, and return the Spouse or Qualified Domestic Partner Certification form (447.9 KB) to:

Washington State Health Care Authority
P.O. Box 42684
Olympia, WA 98504-2684

Please call 1-800-200-1004 to speak with a PEBB Benefits Services representative if you have questions about the enrollment process.