A subscriber must provide a copy of their or their dependent’s Medicare card or entitlement letter from the Social Security Administration with effective dates by uploading it online using Benefits 24/7 (once available) or providing it to the PEBB Program. If a subscriber or their dependent is not enrolled in either Medicare Part A or Part B on their 65th birthday, the subscriber must upload or provide a copy of the denial letter from the Social Security Administration. If this procedural requirement is not met, eligibility will end as described in the termination notice sent by the PEBB Program. The only exception to this rule is for an employee or school employee who retired on or before July 1, 1991. Medicare Part D The PEBB Program has determined that this medical plan has prescription drug coverage that is, on average, as good as or better than the standard Medicare Part D prescription drug coverage (it is “creditable coverage”). Therefore, a subscriber or their enrolled dependent cannot enroll in a Medicare Part D plan and stay in this medical plan. If the subscriber terminates this medical plan, they may contact the PEBB Program to request a certificate of creditable coverage. If creditable prescription drug coverage is not maintained, Medicare Part D premiums may be higher in the future. If a subscriber, or their enrolled dependent chooses to enroll in a Medicare Part D plan, PEBB retiree insurance coverage may only be continued by enrolling in the PEBB-sponsored Medicare supplement plan. When medical coverage begins For an eligible retiring employee or retiring school employee and their eligible dependents, medical coverage begins the first day of the month after the retiring employee’s or retiring school employee’s own employer-paid coverage, COBRA coverage, or continuation coverage ends. For an eligible employee or school employee determined to be retroactively eligible for disability retirement and their eligible dependents, medical coverage begins on the date chosen by the employee or school employee as allowed under PEBB Program rules. For an eligible elected or full-time appointed official and their eligible dependents, medical coverage begins the first day of the month following the date the official leaves public office. For an eligible survivor of a retiree and their eligible dependents, medical coverage will be continued without a gap, subject to payment of premiums and applicable premium surcharges. If the eligible survivor is not enrolled at the time of the retiree’s death, medical coverage will begin the first day of the month following the retiree’s death. For an eligible survivor of an employee or school employee and their eligible dependents, medical coverage begins the first day of the month following the later of the date of the employee’s or the school employee’s death or the date the survivor’s PEBB insurance coverage, educational service district coverage, or SEBB insurance coverage ends. This does not include emergency service personnel killed in the line of duty. For an eligible survivor of an emergency service personnel killed in the line of duty and their eligible dependents, medical coverage begins on the date chosen, as allowed under PEBB Program rules. For a retiree or a survivor who deferred enrollment and is enrolling in a PEBB retiree health plan following loss of other qualifying coverage, medical coverage for the retiree or the survivor and their eligible dependents begins the first day of the month after the loss of the other qualifying coverage. For a retiree, a survivor, or their eligible dependents enrolling during the PEBB Program’s annual open enrollment, medical coverage begins January 1 of the following year. 160 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage