Form Library – Grove XXIII

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 1-877-840-3874

2025 Grove XXIII Medical Benefit Information

Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
Información sobre beneficios	Proporciona una información de alto nivel sobre sus HealthEZ beneficios médicos.
Copay Plan 1 SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Plan de Copay 1 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.
Copay Plan 2 SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Plan de Copay 2 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.
HSA Plan 1 SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Plan de HSA 1 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.
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.

Teladoc Forms

You've Got Teladoc	Talk to a doctor anytime, anywhere by phone or video.
Mobile App Set Up	Use this flyer to help set up the Teladoc Mobile App
Teladoc Web Registration	It’s quick and easy to set up your account online. Simply visit the Teladoc® website.

HealthEZ Resources

Understanding Your ID Card	Provides an easy-to-understand summary about how to read your HealthEZ ID card.
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

EZfit Program Forms & Information

EZFit Enrollment Form	This form is to be filled out if enrolling in the EZFit program.
EZFit Reimbursement Form	This form is to be filled out when needing reimbursements for the EZFit program.

Payer Matrix

Payer Matrix Select Savings	This document offers details about manufacturer assistance programs that can serve as alternative funding sources for specific specialty drugs.

Machine Readable File

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.

Preventive and Wellness Services

Preventive and Wellness Services	Provides information on your common preventive and wellness services.

Precertification

Precertification List	Provides a general overview of common services that require precertification. For specifics, please contact the number at the top of this page.

Coordination of Benefits

Coordination of Benefits (COB) Letter	A Coordination of Benefits (COB) letter is sometimes needed to process claims if you are covered by more than one health plan. It clarifies who pays what by determining which plan is the primary payer and which is secondary. Members will be notified if this form is required.

Important Notices

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.
HealthEZ Privacy Policy	A summary of key provisions of our Privacy Notice.