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

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.
EZSPD An EZ to understand, short version of your Legal SPD.
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.
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.
Claim Reimbursement Form This form is to be filled out when needing reimbursements for medical, dental or pharmacy expenses.
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.
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
No Surprises Act Notice of Rights Under No Surprises Act