Home > Health Insurance Forms and Documents

Documents, Forms and Legal Notices

Click on a category below to find the related documents.

​2021 Forms and Documents, and Legal Notices

Forms 

2021 Employee Benefits Enrollment Change Form
2021 Retiree Enrollment Change Form
2020 ADA Active Enrollment Form
2021 Dental Insurance Enrollment Change Form
2021 Vision Insurance Enrollment Change Form
2021 KEHP Federal Post Tax Request Form
Exception Form
Tobacco Use Change Form

Documents

2021 Benefits Selection Guide
2021 Mini Benefits Selection Guide
2021 Benefits Grid
2021 New Hire Checklist
How to Enroll
LivingWell Regional Well-being Coordinators Territory Map

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
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

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

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

2020 Forms

2020 Benefits Enrollment Change Form
2020 Retiree Enrollment Form
2020 ADA Active Enrollment Form
2020 KEHP Federal Post Tax Request Form
2020 Summer Transfer Application BOEs Only
Exception Form
Credit Request Form
Medicaid Eligibility Termination Form
Retro Cap Override Form
Tobacco Cessation Voucher Form
Tobacco Use Change Form
SmartShopper Incentive List
WageWorks Dependent Care Reimbursement Form
WageWorks Health Reimbursement Form