and their enrolled dependents will be enrolled in the Uniform Medical Plan Classic during the gap month(s) prior to when the MAPD plan begins. For a retiree or a survivor to enroll in a PEBB medical plan, the enrollment must be completed online using Benefits 24/7 (once available) or the PEBB Program must receive a PEBB Retiree Election Form (form A), any other required forms, supporting documents, and evidence of continuous enrollment in one or more qualifying coverages during the timelines described in this section. A gap in coverage of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages during the deferral period. A retiree or a survivor who deferred their enrollment in PEBB retiree insurance coverage while enrolled in qualifying coverage as described above may also enroll in a PEBB medical plan if they receive formal notice that HCA has determined it is more cost-effective to enroll in a PEBB medical plan than a medical assistance program. A retiree or a survivor should contact the PEBB Program or visit hca.wa.gov/pebb-retirees to get the required forms, information on premiums, and a list of available medical plans. Making changes during annual open enrollment and special open enrollment A subscriber may make certain changes to their enrollment during the annual open enrollment and if a specific life event creates a special open enrollment period. Annual open enrollment changes A subscriber may make the following changes to their enrollment during the PEBB Program’s annual open enrollment period: • Enroll in a medical plan following a deferral • Defer or terminate their enrollment in a medical plan • Enroll or remove eligible dependents • Change their medical plan A subscriber must submit the election change online using PEBB My Account or Benefits 24/7 (once available) or submit the required PEBB Retiree Election Form (form A-OE) along with any other required forms, and any supporting documents to the PEBB Program. The change must be completed online or the forms must be received no later than the last day of the annual open enrollment period and will be effective January 1 of the following year. Special open enrollment changes A subscriber may change their enrollment outside of the annual open enrollment period if a qualifying event creates a special open enrollment period. However, the change in enrollment must be allowable under Internal Revenue Code (IRC) and Treasury Regulations and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, their dependent, or both. The subscriber must provide evidence of the event that created the special open enrollment. To disenroll from a Medicare Advantage (MA) plan or Medicare Advantage Prescription Drug (MAPD) plan, the change in enrollment must be allowable under federal regulations. To make an enrollment change, the subscriber must submit the change online using Benefits 24/7 (once available) or submit the required PEBB Retiree Change Form (form E) along with any other required forms to the PEBB Program. The change must be completed online or the PEBB Program must receive the forms no later than 60 days after the event that creates the special open enrollment. In addition, the PEBB 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 163