Form Library

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

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2025 Medical Benefit Information
 
Benefit Overview Provides a high level overview of your HealthEZ medical benefits.
Cigna Plan SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
PHCS Plan SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
2025 Summary Plan Description (SPD) - CIGNA Provides information on how the medical plan operates, when employees are eligible for benefits, how benefits are paid, and much more.
2025 Summary Plan Description (SPD) - PHCS Provides information on how the medical plan operates, when employees are eligible for benefits, how benefits are paid, and much more.
HealthEZ Resources
 
Boost Your Baby HealthEZ offers maternity support by providing education and resources to promote a healthy pregnancy through postpartum.
HealthEZ EZPay Manage all your medical expenses in one simple spot with EZpay. Everything you need is at your fingertips in the free HealthEZ app.
How to Find Your HealthEZ EOB's & Statements How to find your HealthEZ EOB's & Statements.
Understanding Your ID Card Provides an easy-to-understand summary about how to read your HealthEZ ID card.
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 - 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.
Coordination of Benefits
 
Coordination of Benefits Form Fill out the Coordination of Benefits form and submit to HealthEZ to document any secondary insurance coverage
Member Appeal Form
 
Member Appeal Form Member Appeal Form
Preventive Care Guidelines
 
Preventive Care Guidelines An ounce of prevention is worth a pound of cure. That’s why your health plan fully covers preventive care services. These services are defined by the U.S. Preventive Services Task Force and vary depending on age, sex, and pregnancy. All services classified as Grade A or B are covered at no cost to you.
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 Ac