A retiree or a survivor who voluntarily terminates their enrollment in a medical plan also terminates all other health plan enrollment and enrollment for all eligible dependents. Once coverage is terminated, a retiree or a survivor may not enroll again in the future unless they reestablish eligibility for PEBB insurance coverage by becoming newly eligible. Deferring enrollment An enrolled retiree or survivor may defer enrollment in PEBB retiree insurance coverage at any time by submitting the request online using Benefits 24/7 (once available) or the PEBB Retiree Change Form (form E) along with any other required forms and supporting documents to the PEBB Program. Enrollment in PEBB retiree insurance coverage will be deferred effective the first of the month following the date the request is received online or by the PEBB Program. If the request is received on the first day of the month, enrollment will be deferred effective that day. When a retiree, a survivor, or their dependent is enrolled in a Medicare Advantage or Medicare Advantage Prescription Drug plan, medical plan enrollment will be deferred the first of the month following the date the PEBB Medicare Advantage Plan Disenrollment Form (form D) is received. A retiree or a survivor who deferred their enrollment may enroll as described in “Enrollment following deferral.” Enrollment following deferral A retiree or a survivor who defers enrollment in PEBB retiree insurance coverage: • While enrolled in employer-based group medical or such coverage under COBRA coverage or continuation coverage may enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after the date their enrollment in employer-based group medical coverage or such coverage under COBRA coverage or continuation coverage ends. • While enrolled in a federal retiree medical plan as a retiree or dependent will have a one-time opportunity to enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after their enrollment in a federal retiree medical plan ends. • While enrolled in Medicare Parts A and B and a Medicaid program that provides creditable coverage may enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after their Medicaid coverage ends, or no later than the end of the calendar year when their Medicaid coverage ends if they were also enrolled in a subsidized Medicare Part D plan. • While enrolled in qualified health plan coverage through a health benefit exchange developed under the Affordable Care Act will have a one-time opportunity to enroll or reenroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after exchange coverage ends. • While enrolled in CHAMPVA will have a one-time opportunity to enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after their enrollment in a CHAMPVA medical plan ends. • While enrolled as a dependent in a medical plan sponsored by PEBB or SEBB, including coverage under COBRA or continuation coverage, may enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after the enrollment in a medical plan sponsored by PEBB or SEBB ends, or such coverage under COBRA or continuation coverage ends. The evidence of continuous enrollment required to enroll as described below may include a health plan sponsored by a Washington State educational service district if enrollment was deferred prior to January 1, 2024. Note: Enrollment in the PEBB Program’s Medicare Advantage Prescription Drug (MAPD) plan may not be retroactive. If a subscriber elects an MAPD plan and the online enrollment or the required forms are received by the PEBB Program after the date PEBB retiree insurance coverage is to begin, the subscriber 174 2024 UMP Classic (PEBB) Certificate of Coverage