Form Library – Pink Jeep

Form Library

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

Enrollment Announcement

Open Enrollment Information	This letter will explain the open enrollment process. If you have any questions please contact an HR representative.

Medical Benefit Information

Benefit Overview & Enrollment Form Pink Jeep Arizona	Provides a high level overview of your medical benefits.
Benefit Overview & Enrollment Form Pink Jeep Nevada	Provides a high level overview of your medical benefits.
Benefit Overview & Enrollment Form Pink Jeep Tennessee	Provides a high level overview of your medical benefits.
EZSPD	An EZ to understand, short version of your Legal SPD.
Pink Jeep Arizona Basic Plan 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.
Pink Jeep Arizona Silver Plan 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.
Pink Jeep Nevada Basic Plan 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.
Pink Jeep Nevada Silver Plan 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.
Pink Jeep Tennessee Basic Plan 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.
Pink Jeep Tennessee Silver Plan 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.
Diabetes Testing Supplies	Provides information on HealthEZ's Diabetes program.
Prior Authorization Check	Check this list to see which services DO NOT require Prior Authorization.

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.
Medicare Part D Notice	This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage.

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.

Important Notices

Precertification List	Procedures that commonly require precertification
Your Rights and Protections Against Surprise Medical Bills	When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
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 (HIPAA) 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.