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Search results with tag "Pebb premium surcharge attestation"
2022 PEBB Premium Surcharge Attestation Help Sheet
www.hca.wa.gov2022 PEBB Premium Surcharge Attestation . Help Sheet. Use the information below to determine whether the premium surcharges apply to you. Then attest (respond) in the surcharge sections on your enrollment form or the 2022 PEBB Premium Surcharge Attestation Change form.
2022 Retiree Election Form (Form A)
www.hca.wa.gov2022 PEBB Premium Surcharge Attestation Help Sheet . available at hca.wa.gov/pebb-retirees. for instructions on how to respond. Does the tobacco use premium surcharge apply to you? Check one: No, I am enrolled in Medicare Part A and Part B. The premium surcharge does not apply. Yes, I am subject to the $25 premium surcharge. I have used tobacco ...