Form Library – Cabinet Restylers Benefits

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 Care Advocate call 855-255-7060

2025 Medical Benefit Information

Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
PPO 10 SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
PPO 11 SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
HDHP 3 SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
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

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.
HealthEZ EOB Sample	View a sample of your HealthEZ Explanation of Benefits (EOB)
HealthEZ Statement Sample	View a sample of your HealthEZ Statement
How to find your EOB's & Statements	How to find your EOB's & Statements

Claim Reimbursement Forms

HealthEZ Medical Claim Reimbursement Form	Fill out the Medical Expense Reimbursement Form and submit to HealthEZ when you have paid out of pocket for medical expenses.
WellDyne Pharmacy Reimbursement Form	Fill out the Prescription Reimbursement Form and submit to WellDyne when you have paid out of pocket for prescription expenses.

Recuro Telemedicine

Recuro Flyer	Feeling better is just a click away!

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 Files - 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.

Coordination of Benefits

Coordination of Benefits Form	Fill out the Coordination of Benefits form and submit to HealthEZ to document any secondary insurance coverage

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