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 1-888-592-6148

2022 Medical Benefit Information
 
Benefit Overview Provides a high level overview of your medical benefits.
Enrollment Form This form is to be filled out if electing medical benefits.
Información sobre beneficios Proporciona una información de alto nivel sobre sus beneficios médicos.
Formulario de inscripción Este formulario se debe completar si se eligen beneficios médicos.
Copay 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.
Plan de Copay SBC Ofrece un resumen fácil de entender sobre los beneficios y la cobertura de un plan de salud.
2022 Summary Plan Description Provides information on how the medical plan operates, when employees are eligible for benefits, how services and benefits are calculated, when benefits become vested, when and in what form benefits are paid, how to file claims for benefits, and much more.
Pharmacy Benefit 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.
CMS Medicare Part D Notice Provides information on your current prescription drug coverage and how it compares to Medicare’s, for those considering joining a Medicare Prescription Drug Plan.
Medicare Part D Notice This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage.
Additional Forms & Verbiage
 
Vision Benefit Summary This flyer includes information regarding Santa Fe Animal Shelter's Voluntary Vision Coverage.
Resumen de beneficios de la visión Este folleto incluye información sobre la cobertura de la Visión Voluntaria del Refugio de Animales de Santa Fe.
Santa Fe Vision Provider List Please use this document find a Vision provider's phone number and address.
Dental Benefit Summary This flyer includes information regarding Santa Fe Animal Shelter's Dental Coverage.
Resumen de beneficios dentales Este folleto incluye información sobre la cobertura dental del refugio de animales de Santa Fe.
Life Benefit Summary This flyer includes information regarding Life and Accidental Death & Dismemberment.
Resumen de beneficios de vida Este folleto incluye información sobre la vida y muerte accidental y desmembramiento.
Summary of Dental, Vision, and Life Benefits Provides a complete overview of dental, vision, and life benefits.
Employee Assistance Services (EAP) Learn about the EAP and what benefits it offers. It also goes over pricing and contact information to learn more about its services.
Employee Assistance Program (EAP) FAQs Learn more about the EAP offered through The Solutions Group. From personal to work-related issues, the EAP is there to help.
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. This form can also be used for COVID-19 OTC reimbursement requests
Important Notices
 
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 (HIPPA) 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.