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 1-800-203-1514

Medical Benefit Information
 
Benefit Overview Provides a high level overview of your 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.
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. This form can also be used for COVID-19 OTC reimbursement requests
Pharmacy Benefit Information
 
MagellanRx Member Portal Guide This guide provides step-by-step directions on using your MagellanRx secure member portal.
MagellanRx Mail Service Order Form Use this form for mail order prescriptions from MagellanRx.
MagellanRx Mail Service FAQ This guide provides information on ordering your medication by mail, and frequently asked question.
MagellanRx Generics This guide provides information on how to save money by choosing quality, cost-effective alternatives to brand medications.
MagellanRx Medication Adherence This guide provides information on promoting healthier outcomes and reducing medical complications.
MagellanRx Cares This guide provides information on the MagellanRx Cares program.
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
 
Summary Plan Description Provides information on how the medical plan operates, when employees are eligible for benefits, how services and benefits are calculated, when benefits became vested, when and in what form benefits are paid, how to file claims for benefits, and much more.
Marketplace Notice Explains options for purchasing health coverage through the Insurance Marketplace.
EZFit Information
 
EZFit Program Highlights Provides a high level overview of your EZFit program benefits.
EZFit Reimbursement Form This form is to be filled out when needing reimbursements for the EZFit program.
Important Notices
 
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 (HIPPA) 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.