Form Library

Below you’ll find links to information and forms, which you can view or download and print.

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Medical Benefit Information
 
Benefit Overview Provides a high level summary of your medical plans benefits.
Medical Benefit Summary Provides details on your medical plans benefits.
Medical Enrollment Form This form is to be filled out if electing medical benefits.
Cigna Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Bronze Copay Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
PHCS Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Bronze Copay Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Diabetes Program Diabetes Program will match you with a health coach to help with managing your diabetes.
Summary Plan Description 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.
COVID-19 OTC Test Claim Reimbursement Form Use this form for your over-the-counter Covid-19 test reimbursement.
Pharmacy Documents
 
Medicare Part D Notice This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage.
Ancillary Benefits
 
Vision Benefits Summary Your vision benefits summary administered through VSP.
Dental High Plan Benefits Summary This document provides details of your dental high plan benefits.
Dental Low Plan Benefits Summary This document provides details of your dental low plan benefits.
GAP Benefit Summary This document provides details of your TransAmerica Gap Policy.
Accident Only Insurance Summary Provides you a brief summary of the key accident-only benefits available from Transamerica Life Insurance Company.
Voluntary Term Life Insurance Summary Provides you a brief summary of the voluntary term life insurance benefits available from Principal Life Insurance Company.
Short Term Disability Coverage Summary Provides you a brief summary of the key short term disability benefits available from Principal Life Insurance Company.
Long Term Disability Coverage Summary Provides you a brief summary of the key long term disability benefits available from Principal Life Insurance Company.
Group Term Life Insurance Summary Provides you a brief summary of the key group term life insurance benefits available from Principal Life Insurance Company.
Critical Illness Insurance Summary Provides you a brief summary of the key group term life insurance benefits available from Transamerica Life Insurance Company.
Machine Readable File
 
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.
Machine Readable File - Center Care Network KY 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 - Community Health (MT) 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 - Cigna IPN 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 - HAP Network (MI) 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 - Health Partners Cigna (MN) 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 - Missouri Health Partners Cigna 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.