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 952-896-9104

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2026 Medical Benefit Information
 
2026 Benefit Overview Provides a high level overview of your HealthEZ medical benefits.
APPO/Aetna Copay Plan SBC Document Provides an easy-to-understand summary about a health plan’s benefits and coverage.
APPO/Aetna HSA Plan SBC Document Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Elite Network HSA Plan SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
2026 Medical Summary Plan Description (SPD) The Summary Plan Description for the plan year effective 1/1/2026 has yet to be finalized and will be posted once available. In the meantime, if you have questions on your plan's benefits, please contact the number at the top of this page.
2025 Medical Benefit Information
 
2025 Benefit Overview Provides a high level overview of your HealthEZ medical benefits.
APPO/Aetna Copay Plan SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
APPO/Aetna HSA Plan SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Elite Network HSA Plan SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
2025 Medical and Dental Premiums Provides an easy-to-understand summary of your premiums for your HealthEZ Medical and Dental Plan.
Vision Benefit Overview Provides a high level overview of your vision plan benefits.
VSP/Reliance Standard Privacy Notice A summary of key provisions of Reliance's Privacy Notice.
HealthEZ Care Navigation Resources Provides an overview of the medical management services provided through HealthEZ.
Special Enrollment Notice HealthEZ Special Enrollment Notice
Teladoc Flyer You’ve got Teladoc virtual health!
2025 Medical 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.
2025 Dental Summary Plan Description (SPD) Provides information on how the dental plan operates, when employees are eligible for benefits, how benefits are paid, and much more.
HealthEZ Resources
 
Member App Instructions Provides instructions on downloading the MyHealthEZ app and creating an online account.
Member Portal Overview A brief video overview of your MyHealthEZ portal where you be able to find EOBs, statements, accumulator data, ID cards, and so much more.
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.
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.
Prime Therapeutics PBM Information
 
HSA Preventative Drug List This document is a summary of preventative medications.
Retail Pharmacy Listing A listing of national and regional retail pharmacies that participate in Prime Therapeutics’ broadest commercial pharmacy network
Home Delivery Pharmacy Flyer Provides an overview of home delivery with Prime Therapeutics Pharmacy
PrimeCentral App Information Provides information on Prime Therapeutics Mobile App
Member Portal Guide Additional information on using Prime Therapeutics member portal
Accord Quick Reference Guide Provides an overview of Accord, a quick formulary reference guide
Care Specialists Specialty Pharmacy Provides information on Care Specialists program
Specialty Pharmacy Overview Additional information on Prime Therapeutics Specialty Pharmacy
Understanding Prior Authorization Provides an overview of the Prior Authorization (PA) process
Understanding Pharmacy Benefits Provides an introduction of Prime Therapeutics
Step Therapy Overview Additional information on Step Therapy
Select Savings Overview Provides information on ways to save on Specialty Medicines
Affordable Care Act (ACA) Preventive Drug List Accord™ Formulary Affordable Care Act (ACA) Preventive Drug List Accord™ Formulary
HSA Preventive Drug List Accord™ Formulary HSA Preventive Drug List Accord™ Formulary
Accord Formulary Drug Search Accord Formulary Drug Search
2025 Ancillary Benefit Information
 
2025 Ancillary Benefit Overview Guide Provides an overview of your Ancillary Benefits
Voluntary Group Long Term Disability Overview Provides a high level overview of your Voluntary Group Long Term Disability Insurance benefits
Long Term Disability Rate Tables Provides a cost breakdown of Long Term Disability Benefits.
Group Supplemental and Dependent Life Overview Provides a high level overview of your Group Supplemental and Dependent Life Insurance benefits
Supplemental and Dependent Life Insurance Premium Table Provides an easy-to-understand summary of your Employee Bi-Weekly Premiums for your Supplemental and Dependent Life Insurance Plan
Voluntary AD&D Overview Provides a high level overview of your Voluntary AD&D Insurance benefits
Voluntary AD&D Insurance Premium Table Provides an easy-to-understand summary of your Bi-Weekly Premiums for your Voluntary AD&D Insurance Plan
Group Basic Life and AD&D Class 1 Overview Provides a high level overview of your Group Basic Life and AD&D Class 1 plan highlights
Group Basic Life and AD&D Class 2 Overview Provides a high level overview of your Group Basic Life and AD&D Class 2 plan highlights
Reliance Standard Enrollment Form This form is to be filled out if electing a Reliance Standard Insurance plan
Employee Assistance Program Benefits Flyer Provides an overview of your Employee Assistance Program benefits.
Employee Assistance Program Member Portal and App Flyer Provides an overview of the Employee Assistance Program Member Portal and App.
Employee Assistance Program FAQs and Guidelines Provides an overview of the Employee Assistance Program FAQs and Guidelines.
MICO Program Flyer Provides an overview of the OptiMed MICO Program benefits.
Merging MyHealthEZ Portal Accounts Provides an overview of merging portal accounts
Surgical & Imaging Flyer Provides an overview of the Surgical and Imaging benefit offered through Vālenz.
Prescription Cost Savings Flyer Provides an overview of the Prescription Cost Savings Program
SAR Medical/Dental Form 2024 Medical/Dental Summary Annual Report
WEX Benefit Information
 
WEX Login Participant Site WEX login for HSA, FSA and COBRA
2025 401K Savings Plan
 
Ascensus 401(k) Participant Login Ascensus 401(k) Participant Login
401K Savings Plan Summary Plan Description Provides detailed information on how the 401K Savings Plan operates and much more.
EZfit Program Forms & Information
 
EZFit Program Highlights Provides a high level overview of your EZFit program benefits.
EZFit Enrollment Form This form is to be filled out if enrolling in the EZFit program.
EZFit Reimbursement Form This form is to be filled out when needing reimbursements for the EZFit program.
LifeTime Fitness Corporate Membership Sign Up Link
Machine Readable Files
 
Machine Readable Files - America's PPO 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 Files - Aetna 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 Files - 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