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 855-290-1414

Medical Benefit Information
 
Benefit Overview Pink Jeep Arizona Provides a high level overview of your medical benefits.
Enrollment Form - Arizona This form is to be filled out if electing medical benefits.
Benefit Overview Pink Jeep Nevada Provides a high level overview of your medical benefits.
Enrollment Form - Nevada This form is to be filled out if electing medical benefits.
EZSPD An EZ to understand, short version of your Legal SPD.
Pink Jeep Arizona Basic Plan SBC 2018 The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Pink Jeep Arizona Silver Plan SBC 2018 The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Pink Jeep Nevada Basic Plan SBC 2018 The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Pink Jeep Nevada Silver Plan SBC 2018 The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Network Documents
 
AFMC Urgent Care Listing This is a listing of state wide Urgent Care Centers in the Arizona Foundation for Medical Care (AFMC)network.
Pharmacy Benefit Information
 
CVS/Caremark Home Delivery Service Overview Provides on overview on the benefits of CVS/Caremark Home Delivery Service.
CVS/Caremark Home Delivery Service Guide Provides information on how to use CVS/Caremark Home Delivery Service.
CVS/Caremark FAQ Frequently asked questions about CVS/Caremark Prescription Benefits and Home Delivery Service.
CVS/Caremark Home Delivery Service Form Use this form for mail order prescriptions from CVS/Caremark.
CVS/Caremark Home Delivery Service Form - Spanish Use this form for mail order prescriptions from CVS/Caremark.
CVS/Caremark Website Guide Provides information on how to use the CVS/Caremark website.
CVS/Caremark Mobile Application Provides information on how to use the CVS/Caremark mobile app.
Plan Documents
 
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.
Marketplace Notice Explains options for purchasing health coverage through the Insurance Marketplace.
CMS Medicare Part D Notice Provides information for eligible Medicare Part D members on whether or not your current prescription drug coverage is creditable compared to Medicare's.
Important Notices
 
Notice of Electronic Disclosure Notice of Electronic Disclosure of Employee Benefit Notices, Summary of Plan Description, and Plan Amendments.
Paper Employee Notice Acknowledgement of Paper Employee Benefit Notices.
COBRA Notice Explains your right to continue health benefits, if you were to lose them through your group health plan.
Special Enrollment Notice Explains your right to enroll in your group health plan, if you lose your "other" health coverage.
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.
Newborn Act Notice Explains important protections for mothers and their newborn children.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice. Explains how medical information about you may be used and disclosed.
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.