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 1-888-204-7871

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.
Claim Reimbursement Form This form is to be filled out if requesting a reimbursement on a claim.
EZSPD An EZ to understand, short version of your Legal SPD.
$500 Copay 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.
Preferred $5,000 Copay 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.
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 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 prescription 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.
Flexible Spending Account (FSA) Forms & Information
 
FSA Overview & Eligible Expenses Provides a high level overview on FSA’s, eligible expenses, contributions, reimbursements, and much more.
FSA Enrollment Form This form is to be filled out if electing a flexible spending account.
FSA Reimbursement Form This form is to be filled out when needing reimbursements for medical, dental, pharmacy, or vision expenses.
FSA Summary Plan Description Provides information on how the FSA 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.
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