Form Library – American Conservation Experience 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 HealthEZ representative, call 1-888-806-3142

2026 Medical Benefit Information

Benefit Overview	Provides a high level overview of your medical benefits.
Copay Plan 1 SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Copay Plan 2 SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
HSA Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
2026 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.
Understanding Your ID Card	Provides an easy-to-understand summary about how to read your HealthEZ ID card.
24/7 Help Line	The HealthEZ 24/7 Helpline gives members free, confidential support for health questions, symptoms, medications, and care decisions. Help is available by phone anytime, with calls returned within four hours.

EZFit

EZFit Overview and Reimbursement Form	EZFit from HealthEZ makes it easy for you to get credit for health club workouts.

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.

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 - Behavioral 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.

Prime Therapeutics PBM Information

HSA Preventative Drug List	This document is a summary of preventative medications.
Retail Pharmacy Listing	A listing of national and regional retail pharmacies that participate in Prime Therapeutics’ broadest commercial pharmacy network
Home Delivery Pharmacy Flyer	Provides an overview of home delivery with Prime Therapeutics Pharmacy
PrimeCentral App Information	Provides information on Prime Therapeutics Mobile App
Member Portal Guide	Additional information on using Prime Therapeutics member portal
Accord Quick Reference Guide	Provides an overview of Accord, a quick formulary reference guide
Care Specialists Specialty Pharmacy	Provides information on Care Specialists program
Specialty Pharmacy Overview	Additional information on Prime Therapeutics Specialty Pharmacy
Understanding Prior Authorization	Provides an overview of the Prior Authorization (PA) process
Understanding Pharmacy Benefits	Provides an introduction of Prime Therapeutics
Step Therapy Overview	Additional information on Step Therapy
Select Savings Overview	Provides information on ways to save on Specialty Medicines
Affordable Care Act (ACA) Preventive Drug List Accord™ Formulary	Affordable Care Act (ACA) Preventive Drug List Accord™ Formulary
HSA Preventive Drug List Accord™ Formulary	HSA Preventive Drug List Accord™ Formulary
Accord Formulary Drug Search	Accord Formulary Drug Search

Ancillary Benefits

Ancillary Plan Benefit Overview	Provides a high level overview of the ancillary plan.
Regence BCBS FocalPoint SBC	The Summary of Benefits and Coverage provides simple and consistent information about covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Regence BCBS ValueCare SBC	The Summary of Benefits and Coverage provides simple and consistent information about covered benefits, coverage limitations, cost sharing provisions, and exceptions.

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.

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.

Precertification List

Precertification List	Common services that require precertification. For services not listed, contact the number at the top of this page for more information.

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