Form Library

Everything you need in one place.

Below you’ll find links to information and forms, which you can view or download and print.

If you prefer talking with a HealthEZ representative, call 1-800-948-5988

Dr On Demand
 
Dr On Demand: How to use The Doctor On Demand Member Support team is available 24/7/365.
2021 - 2022 Medical Benefit Information
 
Copay Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
HSA Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
High Value Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Claim Reimbursement Form This form is to be filled out when needing reimbursements for medical, dental or pharmacy expenses.
2020 - 2021 Medical Benefit Information
 
Benefit Overview Provides a high level overview of your medical benefits.
Enrollment Form This form is to be filled out if electing medical benefits.
EZSPD© An EZ to understand, short version of your Legal SPD.
Copay Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
HSA Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
High Value Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
High Value Plan Providers List A complete list of all the the providers in the High Value Plan Network.
Prior Authorization Check Check this list to see which services DO NOT require Prior Authorization.
Marketplace Notice Explains options for purchasing health coverage through the Insurance Marketplace.
CMS Medicare Part D Notice Provides information for eligible Medicare Part D members on whether or not your current prescription drug coverage is creditable compared to Medicare's.
Flexible Spending Account (FSA) Forms & Information
 
FSA Calculator Worksheet Use this form to help you decide how much to set aside in your Dependent Care FSA.
FSA Reimbursement Form This form is to be filled out when needing reimbursements for medical, dental, pharmacy, or vision expenses.
Pharmacy Benefit Information
 
CVS/Caremark Home Delivery Service Overview Provides on overview on the benefits of CVS/Caremark Home Delivery Service.
CVS/Caremark Home Delivery Service Guide Provides information on how to use CVS/Caremark Home Delivery Service.
CVS/Caremark FAQ Frequently asked questions about CVS/Caremark Prescription Benefits and Home Delivery Service.
CVS/Caremark Home Delivery Service Form Use this form for mail order prescriptions from CVS/Caremark.
CVS/Caremark Home Delivery Service Form - Spanish Use this form for mail order prescription from CVS/Caremark.
CVS/Caremark Website Guide Provides information on how to use the CVS/Caremark website.
CVS/Caremark Mobile Application Provides information on how to use the CVS/Caremark mobile app.
Medicare Part D Notice This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage.
Plan Documents
 
Medical Summary Plan Description Provides detailed information about your medical benefits.
FSA Summary Plan Description Provides detailed information about your flexible spending account benefits.
Merge Online Accounts
 
Merge Instructions Steps to merge your 2020 and 2021 accounts.
Important Notices
 
Paper Employee Benefit Notices Acknowledgement of Paper Employee Benefit Notices
Notice of Electronic Disclosure Notice of Electronic Disclosure of Employee Benefit Notices, Summary Plan Description, and Plan Amendments
CHIP Model Notice Premium Assistance under Medicaid and the Children’s Health Insurance Program
COBRA Notice General COBRA Notice
GINA Booklet The Genetic Information Nondiscrimination Act
HIPAA Notice HIPAA Privacy Notice
Newborns Act Newborns’ and Mothers’ Health Protection Act
Special Enrollment Rights Notice Special Enrollment Rights Notice
WHCRA Women’s Health and Cancer Rights Act