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 1-844-855-0621

Minimum Essential Coverage Benefit Information
 
MEC Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Minimum Essential Coverage (MEC) Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Plan de MEC SBC El Resumen de beneficios y cobertura proporciona información sencilla y coherente sobre su plan médico, beneficios cubiertos, limitaciones de cobertura, disposiciones sobre la cuota de costos y excepciones.
Medical Benefit Information
 
Good Neighbor Benefit Overview Provides a high level overview of your medical benefits.
Información sobre beneficios - Good Neighbor Proporciona una información de alto nivel sobre sus beneficios médicos.
Employer's Choice Benefit Overview Provides a high level overview of your medical benefits.
Información sobre beneficios - Employers Choice Proporciona una información de alto nivel sobre sus beneficios médicos.
EZSPD An EZ to understand, short version of your legal SPD.
$3,000 PPO Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical PPO Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Plan de $3,000 PPO SBC El Resumen de beneficios y cobertura proporciona información sencilla y coherente sobre su plan médico, beneficios cubiertos, limitaciones de cobertura, disposiciones sobre la cuota de costos y excepciones.
Prior Authorization Check Check this list to see which services DO NOT require Prior Authorization.
Enrollment Forms
 
Enrollment Form - Good Neighbor This form is to be filled out if electing medical benefits.
Formulario de inscripción - Good Neighbor Este formulario debe ser llenado si elige beneficios médicos.
Enrollment Form - Employer's Choice This form is to be filled out if electing medical benefits.
Formulario de inscripción - Employers Choice Este formulario debe ser llenado si elige beneficios médicos.
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
 
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- Creditable This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage.
Medicare Part D Notice- Noncreditable This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage.
Plan Documents
 
Full Medical Summary Plan Description Provides information on how the full-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.
Minimum Essential Coverage Summary Plan Description Provides information on how the minimal essential coverage 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-$3,000 PPO Plan Explains options for purchasing health coverage through the insurance Marketplace.
Marketplace Notice-MEC Plan Explains options for purchasing health coverage through the insurance Marketplace.
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.