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 877-251-5809

Questions about your benefits?

service@healthez.com

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2025 Medical Benefit Information
 
Benefit Overview Provides a high level overview of your HealthEZ medical benefits.
$3,500 PPO SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
$6,500 HDHP SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
$4,000 HDHP SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
2025 Summary Plan Description The Summary Plan Description for the plan year effective 12/1/2025 has yet to be finalized and will be posted once available. In the meantime, if you have questions on your plan's benefits, please contact the number at the top of this page.
HealthEZ Resources
 
Member App Instructions Provides instructions on downloading the MyHealthEZ app and creating an online account.
Member Portal Overview A brief video overview of your MyHealthEZ portal where you be able to find EOBs, statements, accumulator data, ID cards, and so much more.
Boost Your Baby HealthEZ offers maternity support by providing education and resources to promote a healthy pregnancy through postpartum.
HealthEZ EZPay Manage all your medical expenses in one simple spot with EZpay. Everything you need is at your fingertips in the free HealthEZ app.
Understanding Your ID Card Provides an easy-to-understand summary about how to read your HealthEZ ID card.
Claim Reimbursement Forms
 
Medical Expense Reimbursement Form Fill out the Medical Expense Reimbursement Form and submit to HealthEZ when you have paid out of pocket for medical expenses.
Pharmacy Reimbursement Form Fill out the Prescription Reimbursement Form and submit to your Pharmacy Benefit Manager (PBM) when you have paid out of pocket for prescription expenses
Ancillary Benefits
 
MICO Program Flyer Provides an overview of the OptiMed MICO Program benefits.
Surgical & Imaging Flyer Provides an overview of the Surgical and Imaging benefit offered through Vālenz.
Machine Readable Files
 
Machine Readable File – Cigna Network Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice.
PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
Machine Readable File – Out of Network Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice.
PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
Member Appeal Form
 
Member Appeal Form Member Appeal Form
Preventive Care Guidelines
 
Preventive Care Guidelines An ounce of prevention is worth a pound of cure. That’s why your health plan fully covers preventive care services. These services are defined by the U.S. Preventive Services Task Force and vary depending on age, sex, and pregnancy. All services classified as Grade A or B are covered at no cost to you.
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 Ac