Form Library – Rubenacker Farms

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 844-855-0623

2025 Medical Benefit Information

Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
HSA Plan 1 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

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.
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.
HealthEZ Claims Member Communication Flyer	Provides information on how your claims will be processed during your health plan transition to HealthEZ

Claim Reimbursement Forms

Medical Expense Reimbursement Forms	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

Ancillary Benefits

MICO Program Flyer	Provides an overview of the OptiMed MICO Program benefits.

Machine Readable Files

Machine Readable Files - Health Link	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.

HealthEZ Resources

HealthEZ Resources	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 Form

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