Form Library – Lifetime

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 1-800-948-3253

Medical Benefit Information

2023 Benefit Booklet	View your entire benefit booklet containing information about all benefits offered to Team Members 2023-2024.
2023 Enrollment Resource Center	Mark your calendar - Open Enrollment will be August 8 - August 24, 2023.
Click here to view the 2023-2024 Open Enrollment Presentation	Open Enrollment Presentation
Copay $1,500 Plan SBC	This is the government-mandated summary of benefit coverage for the Medical Copay Plan.
HSA $2,300 Plan SBC	This is the government-mandated summary of benefit coverage for the Medical HSA $2,300 Plan.
HSA $5,500 Plan SBC	This is the government-mandated summary of benefit coverage for the Medical HSA $5,500 Plan.
Boost Your Baby	Promoting healthy pregnancies and happy moms.
Summary Plan Description (SPD)	Provides information on how the medical plan operates, when employees are eligible for benefits, how benefits are paid, and much more.

Doctor On Demand Telemedicine

Your healthcare just got a whole lot easier!	Provides an overview on available services from Doctor On Demand and how to get started.
Doctor On Demand Support Flyer	The Doctor On Demand Member Support team is available 24/7/365.
Doctor On Demand Account Activation Flyer	Download the Doctor On Demand app for anytime access to top doctors and therapists.
Doctor On Demand- Behavorial Health Flyer	Highly accessible virtual-first coaching, therapy, and psychiatry through Doctor on Demand.
Doctor On Demand- Everyday and Urgent Care Flyer	Immediate, accessible video-first virtual care for members with acute needs.

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
Prescription 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.
Caremark Website Covid Test Receipt Submission	PowerPoint presentation to walk you through the steps to submit electronically at www.caremark.com/covid19-otc

Flexible Spending Account (FSA) Benefit Information

Medical FSA Reimbursement Form	Fill this form out when needing reimbursements for medical, dental, pharmacy or vision expenses. Your FSA Reimbursement Form can be submitted via email, fax, or through your personal online account.
Transportation FSA Reimbursement Form	Fill this form out when needing reimbursements for transit & parking expenses. Your FSA Reimbursement Form can be submitted via email, fax, or through your personal online account.
FSA Direct Deposit Reimbursement	Fill this form out to receive your reimbursement by direct deposit to your choice of bank account.
Medical FSA Summary Plan Description	Provides detailed information about your flexible spending account benefits.
Transportation FSA Summary Plan Description	Provides detailed information about your transportation flexible spending account benefits.

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 Form	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 - 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.
Generic Preventative Prescriptions	High Deductible Health Plan (HDHP) - Health Savings Account (HSA) - Generics Only Preventive Therapy Drug List

Machine Readable File

Machine Readable File – Aetna 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 – Health EOS Multiplan 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 – America’s PPO 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.

Preventative Wellness Services

Preventative Wellness Services	Provides information on your common preventative wellness services.

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.