If the employee does not enroll online or return the form by the deadline, the employee will be enrolled in Uniform Medical Plan Classic and a tobacco use premium surcharge will be incurred. Consequently, dependents cannot be enrolled until the PEBB Program’s next annual open enrollment or when a qualifying event occurs that creates a special open enrollment for enrolling a dependent. Waiving medical enrollment An eligible employee may waive enrollment in PEBB medical if they are enrolled in other employer-based group medical, a TRICARE plan, or Medicare. They may not waive enrollment in PEBB medical if they are enrolled in PEBB retiree insurance coverage. When a retiree becomes eligible for the employer contribution toward PEBB benefits, PEBB retiree insurance coverage will be automatically deferred. If an employee waives enrollment in PEBB medical, the employee cannot enroll eligible dependents. For information on when an eligible employee may waive medical plan enrollment after their initial enrollment period, or to enroll after having waived, see “Making changes.” Continuation coverage enrollment A subscriber enrolling in PEBB Continuation Coverage (COBRA or Unpaid Leave) may enroll by using Benefits 24/7, the online enrollment system (once available), or by submitting the applicable PEBB Continuation Coverage Election/Change form and any supporting documents to the PEBB Program. The online enrollment must be completed or the PEBB Program must receive the election form no later than 60 days from the date the enrollee’s PEBB health plan coverage ended or from the postmark date on the PEBB Continuation Coverage Election Notice sent by the PEBB Program, whichever is later. Premiums and applicable premium surcharges associated with continuing PEBB medical must be made directly to HCA. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends as described above. For more information, see “Options for continuing PEBB medical coverage” and the PEBB Continuation Coverage Election Notice. Retired employee of a former employer group enrollment A retired employee or a retired school employee of a former employer group may enroll and self-pay premiums using Benefits 24/7, the online enrollment system (once available), or by submitting the PEBB Continuation Coverage (Employer Group Ended Participation) Election/Change form and any supporting documents to the PEBB Program. The online enrollment must be completed or the PEBB Program must receive the required form no later than 60 days after the employer group ended their participation. Premiums and applicable premium surcharges associated with continuing PEBB medical must be made directly to HCA. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends as described above. Note: Enrollment in the PEBB Program’s Medicare Advantage Prescription Drug (MAPD) plan may not be retroactive. If a subscriber elects a MAPD plan and the online enrollment or the required forms are received by the PEBB Program after the date PEBB health plan coverage is to begin, the subscriber 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. Dependent enrollment To enroll an eligible dependent, the subscriber must include the dependent’s information online using Benefits 24/7 (once available) or on the applicable enrollment form and provide the required document(s) as proof of the dependent’s eligibility. The dependent will not be enrolled in PEBB health plan coverage if the PEBB Program or the employing agency is unable to verify their eligibility within the PEBB Program enrollment timelines. 2024 UMP Select (PEBB) Certificate of Coverage 145