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

2022 Medical Benefit Information

Benefit Booklet	View your entire benefit booklet containing information about all benefits offered to Team Members 2022-2023.
Enrollment Resource Center	Mark your calendar - Open Enrollment will be August 3 - August 18, 2022
Click here to view the Open Enrollment Presentation	Open Enrollment Presentation
Copay 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 Copay Plan.
HSA $5,500 Plan SBC	This is the government-mandated summary of benefit coverage for the Medical Copay Plan.

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. This form can also be used for COVID-19 OTC reimbursement requests
Caremark Website Covid Test Receipt Submission	PowerPoint presentation to walk you through the steps to submit electronically at www.caremark.com/covid19-otc

HealthiestYou Telemedicine

Your healthcare just got a whole lot easier!	With HealthiestYou you can connect with a doctor who can diagnose, treat, and prescribe over the phone 24/7/365.
Welcome to the better way to get healthy skin	If you're having problems with your skin, HealthiestYou Dermatology can help.
A calm mind is a tap away	HealthiestYou's licensed therapists are available seven days a week. Choose your therapist, pick a time that is convenient for you, and then talk to the therapist from the privacy of home or anywhere you feel comfortable.

Flexible Spending Account (FSA) Benefit Information

Flexible Spending Account (FSA) Calculator Worksheet	Use this form to help you decide how much to set aside in your Health Care Reimbursement or Dependent Care FSA.
Eligible Expenses	This document is an overview of eligible expenses.
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.

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

Plan Documents

HIPAA Notification	This notice details Life Time Fitness HIPAA compliance.
EZSPD	An EZ to understand, short version of your Legal SPD.
Summary Plan Description (SPD)	Provides information on how the 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.
Summary Plan Description (FSA)	Provides information on how the FSA 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.
Summary Plan Description (Transportation)	Provides information on how the Transportation Benefits 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	Explains options for purchasing health coverage through the Insurance Marketplace.

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.

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.