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 844-855-0621

Medical Benefit Information
 
Benefit Overview Provides a high level overview of your HealthEZ medical benefits.
PPO (Copay 1) SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
HDHP (HSA 1) Plan SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
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.
Pharmacy Reimbursement Form Fill out the Prescription Reimbursement Form and submit to your Pharmacy Benefit Manager (TrueRX) when you have paid out of pocket for prescription expenses.
Ancillary Services
 
Cost of Benefits Flyer Cost of Benefits (Semi-weekly/Pay Per Period)
DMO Dental Benefits Summary DMO Dental Benefits Summary
DPPO Dental Benefits Summary DPPO Dental Benefits Summary
EyeMed Benefits Summary EyeMed Benefits Summary
One Medical- Virtual Care Flyer Provides an overview of your One Medical Virtual Care benefits.
One Medical- Account Activation Flyer Download the One Medical app to easily book appointments, request prescriptions, get care 24/7, message providers, view your care plan, and more.
One Medical- Billing and Cost FAQ Frequently Asked Questions regarding cost and billing for services provided to you through One Medical.
Machine Readable File Cigna Network
 
Machine Readable File – Cigna 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.
Preventative Wellness Services
 
Preventative Wellness Services Provides information on your common preventative wellness services.
Important Notices
 
Precertification List Procedures that commonly require precertification
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.