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 1-844-855-0620

Medical Benefit Information
 
Medical Benefit Overview Provides a high level overview of your medical benefits.
Medical Enrollment Form This form is to be filled out if electing medical benefits.
EZSPD© An EZ to understand, short version of your Legal SPD.
PPO 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.
Flexible Spending Account (FSA) Forms
 
FSA Overview and Eligible Expenses This guide provides step-by-step directions on using your MagellanRx secure member portal.
Flex Reimbursement Form This form is to be filled out when needing reimbursements for medical, dental, pharmacy, or vision expenses.
Pharmacy Forms & 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.
Plan Documents
 
Medical Summary Plan Description The Summary Plan Description provides detailed information about your medical benefits.
FSA Summary Plan Description The Summary Plan Description provides detailed information about your flexible spending account benefits.
Marketplace Notice of Coverage Options 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.
Important Notices
 
Notice of Electronic Disclosure Notice of Electronic Disclosure of Employee Benefit Notices, Summary of Plan Description, and Plan Amendments.
Paper Employee Notice Acknowledgement of Paper Employee Benefit Notices.
COBRA Notice Explains your right to continue health benefits, if you were to lose them through your group health plan.
Special Enrollment Notice Explains your right to enroll in your group health plan, if you lose your "other" health coverage.
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.
Newborn Act Notice Explains important protections for mothers and their newborn children.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice. Explains how medical information about you may be used and disclosed.
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.