Form Library – Ethos Group

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 1-844-804-8120

2026 Medical Benefit Information

Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
Copay Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
HSA $3,000 Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
2026 Summary Plan Description (SPD)	The Summary Plan Description for the plan year effective 1/1/2026 has yet to be finalized and will be posted once available. In the meantime, if you have questions on your plan's benefits, please contact the number at the top of this page.

2025 Medical Benefit Information

Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
Copay Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
HSA $3,000 Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Network Update Notice	Provides additional information and action items required with the change in medical network for the 2025 plan year.
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

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.

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 - EHiM	Fill out the Prescription Reimbursement Form and submit to your Pharmacy Benefit Manager (PBM) when you have paid out of pocket for prescription expenses through 12/31/2025.
Prescription Reimbursement Form - Prime Therapeutics	Fill out the Prescription Reimbursement Form and submit to your Pharmacy Benefit Manager (PBM) when you have paid out of pocket for prescription expenses effective 01/01/2026.

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.

HealthJoy

HealthJoy Overview	Provides an overview of your HealthJoy with Teladoc benefits.

Ancillary Benefits

Surgical & Imaging Flyer	Provides an overview of the Surgical and Imaging benefit offered through Vālenz.

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.
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.
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.

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