Annual Open Enrollment Changes An employee may make the following changes to their enrollment during the PEBB Program’s Annual Open Enrollment period:  Change their medical plan  Waive their medical plan enrollment  Enroll after waiving medical plan enrollment  Enroll or remove eligible Dependents An employee must submit the election change online using PEBB My Account or Benefits 24/7 (once available) or submit the required PEBB Employee Enrollment/Change form and any supporting documents to their Employing Agency. The change must be completed online, or the forms received no later than the last day of the Annual Open Enrollment period and will be effective January 1 of the following year. Any other Subscriber may make the following changes to their enrollment during the PEBB Program’s Annual Open Enrollment period:  Enroll in or terminate enrollment in a medical plan  Change their medical plan  Enroll or remove eligible Dependents A Continuation Coverage Subscriber must submit the election change online using PEBB My Account or Benefits 24/7 (once available) or submit the required PEBB Continuation Coverage (COBRA) Election/Change, or PEBB Continuation Coverage (Unpaid Leave) Election/Change form (as appropriate) and any supporting documents to the PEBB Program. The change must be completed online, or the forms received, no later than the last day of the Annual Open Enrollment period and will be effective January 1 of the following year. A retired employee of a former employer group must submit the election change online using PEBB My Account or Benefits 24/7 (once available) or submit the required PEBB Continuation Coverage (Employer Group Ended Participation) Election/Change form and any supporting documents to the PEBB Program. The change must be completed online, or the forms 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. A special open enrollment event must be other than an employee gaining initial eligibility or regaining eligibility for PEBB benefits. The Subscriber must provide evidence of the event that created the special open enrollment. A special open enrollment may allow a Subscriber to make the following changes:  Enroll in or change their medical plan  Waive their medical plan enrollment  Enroll after waiving medical plan enrollment  Enroll or remove eligible Dependents To request a special open enrollment: EWCLGHDHP1983ACT0124 22 WAPEBB-CD-ACT