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.

HealthEZ Resources

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.

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.

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.

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.
Pharmacy 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

Ancillary Benefits

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.

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