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Documents, Forms and Legal Notices

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​2023 Forms and Documents

Documents

2023 Benefits Selection Guide

​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

​2021 Forms and Documents, and Legal Notices

Forms 

2022 Employee Benefits Enrollment Change Form
2021 Employee Benefits Enrollment Change Form
2021 Retiree Enrollment Change Form
2021 ADA Active Enrollment Form
2021 Dental Insurance Enrollment Change Form
2021 Vision Insurance Enrollment Change Form
2021 KEHP Federal Post Tax Request Form
2021 Checklist for New Employees
Exception Form
Medicaid Eligibility Termination Form
Tobacco Use Change Form

Documents

2022 Benefits Selection Guide
2021 Benefits Selection Guide
2021 Mini Benefits Selection Guide
2021 Benefits Grid
How to Enroll

LivingWell CDHP

Medical Benefit Booklet
RX SPD
2021 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

2021 Waiver General Purpose HRA SPD
2021 Waiver Limited Purpose HRA SPD

Flexible Spending Account

2021 Child and Adult Daycare FSA SPD
2021 Healthcare FSA SPD

Plan Amendments

2021 KEHP Plan FSA DCFSA Elect Change SMM
2021 KEHP FSA Forfeiture SMM
2020 FSA DCFSA Election Change SMM
2020 FSA Run-Out SMM for PY 2020
2020 FSA Run-Out SMM for PY 2019
2020 FSA Medical Expense SMM
2020 FSA Carryover and MidYear Election SMM
2020 HRA Run-Out SMM for PY 2020
2020 HRA Run-Out SMM for PY 2019
2020 HRA Medical Expense SMM

Legal Notices

2021 Legal Notice
2021 Terms and Conditions
2021 Tobacco Use Declaration
2021 COBRA Dental Vision Notice
2021 COBRA Health Notice
2021 Kentucky Marketplace Notice Parts A and B
2021 Kentucky Marketplace Notice Part A Only
2021 Medicare Prescription Drug Creditable Coverage Notice
2021 USERRA Notice on Health Insurance Rights
2021 WHCRA Notice
2021 Well-being Program Notice
2021 CHIP Notice
2021 Notice of Privacy Practices

Pharmacy

Member-Friendly ACA Preventive Services List
ACA Preventive Services List
2021 Preventive Therapy Drug Benefit List
2021 Value Formulary
2021 Advanced Control Specialty Formulary
PrudentRX Specialty Drug List for LivingWell PPO

Prior Authorization Lists

Prior Authorization Value Formulary
Prior Authorization Specialty Drugs

Life Insurance

2021 Life Enrollment and Beneficiary Form
2021 Life Insurance Booklet
2021 Life Insurance Rates

Summaries of Benefits and Coverage

2021 LivingWell CDHP SBC
2021 LivingWell PPO SBC
2021 LivingWell Basic CDHP SBC
2021 LivingWell Limited High Deductible SBC
2021 SBC Glossary