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Documents, Forms and Legal Notices

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​2023 Forms and Documents

Forms 

2023 Employee Benefits Enrollment Change Form
2023 Retiree Enrollment Change Form
2023 ADA Active Enrollment Form
2023 Dental Insurance Enrollment/Change Form
2023 Vision Insurance Enrollment/Change Form
2023 DD Open Enrollment Enrollment Form
2023 KEHP Federal Post Tax Request Form
2023 Exception Form
2023 Checklist for New Employees
Tobacco Use Change Form

Documents

2023 Benefits Selection Guide
2023 Benefits Grid
How to Enroll
Exception Request Information
2023 Waiver HRA
2023 Waiver Limited Purpose HRA
2023 Basic CDHP HRA
2023 Child & Adult Care FSA
2023 Healthcare FSA
2023 COBRA Rates

Documents in Accessible Format

2023 Benefits Selection Guide 508 Compliant
ADA 2023 Benefits Selection Guide Large Print
2023 Benefit Grids Accessible Format

Legal Notices

Notice of Privacy Practices
KEHP Authorization for Release of Information
KEHP Request for Accounting of Disclosures
KEHP Request for Alternate Communications
KEHP Request for Restrictions
KEHP Request to Amend PHI
KEHP Request to Inspect or Copy PHI
2023 Legal Notices
2023 Terms and Conditions
2023 Tobacco Use Declaration
2023 COBRA Dental Vision Notice
2023 COBRA Health Notice
2023 Kentucky Marketplace Notice Parts A and B
2023 Kentucky Marketplace Notice Part A Only
2023 Medicare Prescription Drug Creditable Coverage Notice
2023 USERRA Notice on Health Insurance Rights
2023 WHCRA Notice
2023 Well-being Program Notice
2023 CHIP Notice

Pharmacy

Member-Friendly ACA Preventive Services List
ACA Preventive Services List
Preventive Therapy Drug Benefit List
2023 Value Formulary
2023 Advanced Control Specialty Formulary
PrudentRX Specialty Drug List for LivingWell PPO

Prior Authorization Lists

2023 Prior Authorization Value Formulary
2023 Prior Authorization Specialty Drugs

Life Insurance

MetLife Enrollment Change Form
MetLife Portability Application
MetLife Rates
MetLife Privacy Notice
MetLife Portability v. Conversion Brochure
MetLife Conversion Application

Summaries of Benefits and Coverage

LivingWell CDHP SBC
LivingWell Basic CDHP SBC
LWPPO SBC
Uniform Glossary 2023

Summary Plan Descriptions and Medical Benefit Booklets

2023 LivingWell CDHP Medical Benefit Booklet
2023 LivingWell Basic CDHP Medical Benefit Booklet
2023 LivingWell PPO Medical Benefit Booklet
2023 RX SPD LivingWell CDHP
2023 RX SPD LivingWell PPO
2023 RX SPD LivingWell Basic CDHP
2023 Waiver Limited Purpose HRA SPD
2023 Child Adult Daycare FSA SPD
2023 Healthcare FSA SPD
2023 Waiver General Purpose HRA SPD
2023 Integrated HRA SPD

​2022 Forms and Documents

Forms 

2022 Employee Benefits Enrollment Change Form
2022 Retiree Enrollment Change Form
2022 ADA Active Enrollment Form
2022 Dental Insurance Enrollment/Change Form
2022 Vision Insurance Enrollment/Change Form
2022 KEHP Federal Post Tax Request Form
Exception Form
Medicaid Eligibility Termination Form
Tobacco Use Change Form
Tobacco Cessation Flyer
Tobacco Cessation Voucher Form

Documents

2022 Benefits Selection Guide
2022 Mini Benefits Selection Guide
2022 Benefits Grid
2022 Checklist for New Employees
How to Enroll

LivingWell CDHP

Medical Benefit Booklet
RX SPD
2022 Integrated HRA SPD

LivingWell PPO

Medical Benefit Booklet
RX SPD

LivingWell Basic CDHP

Medical Benefit Booklet
RX SPD

LivingWell Limited High Deductible Plan

Medical Benefit Booklet
RX SPD

Waiver

2022 Waiver General Purpose HRA SPD
2022 Waiver Limited Purpose HRA SPD

Flexible Spending Account

2022 Child and Adult Daycare FSA SPD
2022 Healthcare FSA SPD

Legal Notices

Notice of Privacy Practices
KEHP Authorization for Release of Information
KEHP Request for Accounting of Disclosures
KEHP Request for Alternate Communications
KEHP Request for Restrictions
KEHP Request to Amend PHI
KEHP Request to Inspect or Copy PHI
2022 Legal Notices
2022 Terms and Conditions
2022 Tobacco Use Declaration
2022 COBRA Dental Vision Notice
2022 COBRA Health Notice
2022 Kentucky Marketplace Notice Parts A and B
2022 Kentucky Marketplace Notice Part A Only
2022 Medicare Prescription Drug Creditable Coverage Notice
2022 USERRA Notice on Health Insurance Rights
2022 WHCRA Notice
2022 Well-being Program Notice
2022 CHIP Notice

Pharmacy

Member-Friendly ACA Preventive Services List
ACA Preventive Services List
Preventive Therapy Drug Benefit List
2022 Value Formulary
2022 Advanced Control Specialty Formulary
PrudentRX Specialty Drug List for LivingWell PPO

Prior Authorization Lists

2022 Prior Authorization Value Formulary
2022 Prior Authorization Specialty Drugs

Summaries of Benefits and Coverage

2022 LivingWell CDHP SBC
2022 LivingWell PPO SBC
2022 LivingWell Basic CDHP SBC
2022 LivingWell Limited High Deductible SBC

Life Insurance

MetLife Enrollment Change Form
MetLife Portability Application
MetLife Rates
MetLife Privacy Notice
MetLife Portability v. Conversion Brochure
MetLife Conversion Application

Espanol

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