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

2025-2026 Medical Benefit Information

2025-2026 Benefit Booklet	View your entire benefit booklet containing information about all benefits offered to Team Members 2025-2026.
2025-2026 Enrollment Resource Center	Provides information on the 2025-2026 Employee Benefits Open Enrollment.
Copay $1,500 Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
HSA $2,300 Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
HSA $5,500 Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
2025-2026 Summary Plan Description (SPD)	The Summary Plan Description for the plan year effective 10/1/2025 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.

2024-2025 Medical Benefit Information

2024-2025 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.

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.
How to Find Your HealthEZ EOB's & Statements	How to find your HealthEZ EOB's & Statements.
Understanding Your ID Card	Provides an easy-to-understand summary about how to read your HealthEZ ID card.

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
MIORA Minnesota Reimbursement Form	Fill out the MOIRA Reimbursement Form and submit to HealthEZ when you have paid out of pocket for medical expenses at a MIORA facility.
MIORA Illinois Reimbursement Form	Fill out the MOIRA Reimbursement Form and submit to HealthEZ when you have paid out of pocket for medical expenses at a MIORA facility.
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.

Pharmacy Benefit Information

Home Delivery Service Overview	Provides on overview on the benefits of CVS/Caremark Home Delivery Service.
Home Delivery Order Guide	Provides information on how to use CVS/Caremark Home Delivery Service.
Register at Caremark	Describes how to register on Caremark.com and steps on downloading the mobile app.
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.

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