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 844-449-5543

Medical Benefit Information
 
Benefit Overview Provides a high level overview of your HealthEZ medical benefits.
HSA Plan SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Copay 1 Plan SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Copay 2 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.
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.
Magellan
 
Magellan Portal Login This guide provides step-by-step directions on using your MagellanRx secure member portal.
Mail Service FAQ This guide provides information on ordering your medication by mail.
Mail Service Order Form Use this form for mail order prescriptions from MagellanRx.
National Chain Pharmacy Listing This is a list of the national chain pharmacies that participate in the Magellan Rx Management commercial pharmacy network.
Preventive Drug List This is a list of preventive medications covered at no cost under the Patient Protection and Affordable Care Act (PPACA).
Generics (do not post on MEC sites) Save money by choosing quality, cost-effective alternatives to brand medications
Medication Adherence This guide provides information on promoting healthier outcomes and reducing medical complications.
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 - 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.
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.