2022 Retiree Election Form (Form A)
is eligible for Medicare, they must enroll and stay enrolled in Part A and Part B to keep PEBB retiree health plan coverage. They are in the process of enrolling in Medicare Part A and Part B. They will submit proof after they receive their entitlement letter or Medicare cards. 1 This field is required for health care services.
Download 2022 Retiree Election Form (Form A)
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