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.
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
 
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.
Important Notices
 
Paper Employee Benefit Notices Acknowledgement of Paper Employee Benefit Notices
Notice of Electronic Disclosure Notice of Electronic Disclosure of Employee Benefit Notices, Summary Plan Description, and Plan Amendments
CHIP Model Notice Premium Assistance under Medicaid and the Children’s Health Insurance Program
COBRA Notice General COBRA Notice
GINA Booklet The Genetic Information Nondiscrimination Act
HIPAA Notice HIPAA Privacy Notice
Newborns Act Newborns’ and Mothers’ Health Protection Act
Special Enrollment Rights Notice Special Enrollment Rights Notice
WHCRA Women’s Health and Cancer Rights Act