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 844-801-1912

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.
EZSPD© An EZ to understand, short version of your Legal SPD.
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.
HSA 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.
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.
Medicare Part D Notice This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage.
Diabetic Supply Program
 
Care Advocates Provides information about HealthEZ's Care Advocate program.
Diabetes Testing Supplies Provides information about diabetes supplies that are offered through HealthEZ's Diabetes program.
Plan Documents
 
Summary Plan Description Provides detailed information about your medical benefits.
Marketplace Notice Explains options for purchasing health coverage through the Insurance Marketplace.
Health Savings Account (HSA) Forms & Information
 
HSA Overview Provides a high level overview on HSA’s, eligible expenses, contributions, and much more.
HSA Enrollment Form This form is to be filled out if electing a Health Saving’s Account.