Form Library

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

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2025 Medical Benefit Information
 
Employee Benefits Guide Provides an overview of all Revo Employee Benefits
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.
Multiple Tier Plan Design Flyer An Explanation of Your Multiple Tier Medical Plan Design and how you can view Deductible and Out of Pocket Maximums on the MyHealthEZ portal.
2025 Summary Plan Description (SPD) Provides information on how the medical plan operates, when employees are eligible for benefits, how benefits are paid, and much more.
Claim Reimbursement Forms
 
Medical Expense Reimbursement Form Fill out the Medical Expense Reimbursement Form and submit to HealthEZ when you have paid out of pocket for medical expenses
Prescription Reimbursement Form Fill out the Prescription Reimbursement Form and submit to your Pharmacy Benefit Manager (PBM) when you have paid out of pocket for prescription expenses.
HealthEZ Resources
 
Boost Your Baby HealthEZ offers maternity support by providing education and resources to promote a healthy pregnancy through postpartum
HealthEZ EZPay Manage all your medical expenses in one simple spot with EZpay. Everything you need is at your fingertips in the free HealthEZ app.
How to Find Your HealthEZ EOB's & Statements How to find your HealthEZ EOB's & Statements
Ancillary Benefits
 
Dr On Demand: How to Use The Doctor On Demand Member Support team is available 24/7/365.
Dr On Demand: How to Register Provides information on registering your Dr On Demand account and adding your HealthEZ coverage information
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.
Machine Readable File
 
Machine Readable File – America’s PPO Network Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice.
PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
Machine Readable File - Aetna Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice.
PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
Machine Readable File - Out of Network Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice.
PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
Preventive and Wellness Services
 
Preventive and Wellness Services Provides information on your common preventive and wellness services.
Precertification
 
Precertification List Provides a general overview of common services that require precertification. For specifics, please contact the number at the top of this page.
Coordination of Benefits
 
Coordination of Benefits (COB) Letter A Coordination of Benefits (COB) letter is sometimes needed to process claims if you are covered by more than one health plan. It clarifies who pays what by determining which plan is the primary payer and which is secondary. Members will be notified if this form is required.
Important Notices
 
Your Rights and Protections Against Surprise Medical Bills When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
Notice of Electronic Disclosure Notice of Electronic Disclosure of Employee Benefit Notices, Summary Plan Description and Plan Amendments
Paper Employee Notices Acknowledgement of Paper Employee Benefit Notices
Children's Health Insurance Program (CHIP) Notice Explains how your eligibility for Medicaid or CHIP may qualify you for premium assistance to pay for your employer's health coverage
COBRA Notice Explains your right to continue health benefits, if you were to lose them through your group health plan.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice Explains how personal health information about you may be used and disclosed.
Newborn Act Notice Explains how important protections for your members and their newborn children.
Special Enrollment Notice Explains your right to enroll in your group health plan, if you lose your "other" health coverage.
The Genetic Information Nondiscrimination Act (GINA) Booklet Explains how discrimination on genetic information is prohibited in group health plan coverage
Women's Health and Cancer Rights Act of 1998 Explains important protections for those who choose to have breast reconstruction, in connection with a mastectomy.
HealthEZ Privacy Policy A summary of key provisions of our Privacy Notice.