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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
Open Enrollment Exception Request
2023 Exception Form
2023 Checklist for New Employees

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

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
2022 Value Formulary
2022 Advanced Control Specialty Formulary
PrudentRX Specialty Drug List for LivingWell PPO

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