Form Library – Anna Banana 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 844-302-7774

2025 Medical Benefit Information

Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
Minimum Essential Coverage Plan (MEC) SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
2025 Summary Plan Description (SPD)	The Summary Plan Description for the plan year effective 1/1/2025 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.

2024 Medical Benefit Information

Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
Minimum Essential Coverage Plan (MEC) SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
2024 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.

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.

Preventive and Wellness Services

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

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.