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Documents, Forms and Legal Notices


​​2025 Forms and Documents

​Plans​

2025 LivingWell Basic CDHP​​
​​​2025 LivingWell CDHP​​
2025 LivingWell P​PO​​
2025 LivingWell H​DHP​​​​​​
2025 Optional Dental Plans​​​​​​
2025 Optional Vision Plans​​​​​​
2025 Optional Life Plans​​​​​​​

Forms 

Employee Benefits Enrollment Change Form
Retiree Enrollment Change Form
ADA Active Enrollment Form
Dental Insurance Enrollment/Change Form
Vision Insurance Enrollment/Change Form
KEHP Federal Post Tax Request Form​​​​
​2025 Open Enrollment Exception Form
Checklist for New Employees​​
Medicaid Eligibility Termination Form​​ ​​
Tobacco Use Change Form​​

Documents

​​​2025​ Benefits Selection Guide
2025 Benefit Selection Guide in Spanish​​​​​​​​​
2025 How to Enroll​​​
2025 Benefits Grid​​​
2025 What's New or Changing​​​​
2025 Premiums
KEHP 2025 BSG 508 Compliant​​​​

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
2025​ Legal Notices
2025​ Terms and Conditions
2025 Tobacco Use Declaration

Pharmacy

Member-Friendly ACA Preventive Services List
ACA Preventive Services List
2025​ ​Value Formulary
KEHP Preventive Drug List​
2025​ Value Formulary Quick Reference
KEHP Value Formulary Drugs Requiring Prior Authorization – Non Specialty​

​Life Insurance

2025 Life Insurance and ADD Certificate of Coverage
MetLife Enrollment Change Form
MetLife Portability Application
MetLife Privacy Notice
MetLife Portability v. Conversion Brochure
MetLife Conversion Application
2025​​​ MetLife Rates

Summaries of Benefits and Coverage

LivingWell CDHP SBC
LivingWell Basic CDHP SBC
LivingWell PPO SBC
LivingWell ​HDHP SBC
LWPPO SBC​​
Uniform Glossary​

​Espanol

FORMULARIO DE INSCRIPCIÓNCAMBIO DE BENEFICIOS PARA EMPLEADOS 2025
Resumen de Bronce Vision
Resumen de Plata VisionOro
Resumen de Oro Vision
Resumen de Bronce Dental
Resumen de Plata Dental
Resumen de Oro Dental


​​​​2024 Forms and Documents

Forms 

Employee Benefits Enrollment Change Form
Retiree Enrollment Change Form
ADA Active Enrollment Form
Dental Insurance Enrollment/Change Form
Vision Insurance Enrollment/Change Form
KEHP Federal Post Tax Request Form
​Exception Form
Checklist for New Employees
Medicaid Eligibility Termination Form​​ ​​
Tobacco Use Change Form
2024 Summer Transfer Form (BOEs only)​​

Documents

2024 Benefit Selection Guide Digi Mag
​​​2024​ Benefits Selection Guide
2024​ Benefits Selection Guide in Spanish​
2024​​ Benefits Grid
2024 How to Enroll
2024 What's New or Changing​
2024 Open Enrollment Highlights​
Exception Request Information
2024 Waiver HRA
2024 Waiver Limited Purpose HRA
2024 ​CDHP HRA
2024 Basic CDHP HRA
2024 Child & Adult Care FSA
2024​ Healthcare FSA
2024 COBRA Rates

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
2024 Legal Notices
2024​ Terms and Conditions
2024 Tobacco Use Declaration
2024 COBRA Dental Vision Notice
2024 COBRA Health Notice
2024 Kentucky Marketplace Notice Parts A and B
2024 Kentucky Marketplace Notice Part A Only
2025 Kentucky Marketplace Notice Parts A and B
2025 Kentucky Marketplace Notice Part A Only
2024 Medicare Prescription Drug Creditable Coverage Notice
2024 USERRA Notice on Health Insurance Rights
2024 WHCRA Notice
2024 Well​being Program Notice
2024 CHIP Notice

Pharmacy

Member-Friendly ACA Preventive Services List
ACA Preventive Services List
2024 ​Value Formulary
KEHP Preventive Drug List​
2024 Value Formulary Quick Reference
PrudentRX Specialty Drug List​
KEHP Specialty Drugs Requiring Specialty Guideline Management (Prior Authorization) Review
KEHP Value Formulary Drugs Requiring Prior Authorization – Non Specialty​

Prior Authorization Lists

2024 Prior Authorization Value Formulary
2024​ Prior Authorization Specialty Drugs

Life Insurance

MetLife Enrollment Change Form
MetLife Portability Application
MetLife Privacy Notice
MetLife Portability v. Conversion Brochure
MetLife Conversion Application
2024​​​ MetLife Rates

Summaries of Benefits and Coverage

LivingWell CDHP SBC
LivingWell Basic CDHP SBC
LWPPO SBC
Uniform Glossary​

Summary Plan Descriptions and Medical Benefit Booklets

2024 LivingWell CDHP Medical Benefit Booklet
2024 LivingWell Basic CDHP Medical Benefit Booklet
2024​ LivingWell PPO Medical Benefit Booklet
​​​2024 Waiver Limited Purpose HRA SPD
2024 Healthcare FSA SPD
2024 Integrated HRA SPD
2024 Waiver General Purpose HRA SPD
2024​ Child Adult Daycare FSA SPD​
​​ 2024 RX SPD LIVINGWELL CDHP
2024 RX SPD LivingWell Basic CDHP
2024 RX SPD LIVINGWELL PPO​

Espanol

Vista comparativa de la tabla de beneficios
Resumen de Bronce Vision
Resumen de Plata VisionOro
Resumen de Oro Vision
Resumen de Bronce Dental
Resumen de Plata Dental
Resumen de Oro Dental
2023​ Red de beneficios
FORMULARIO DE INSCRIPCIÓN/MODIFICACIÓN DE BENEFICIOS PARA EMPLEADOS 2024
FORMULARIO DE EXCEPCIÓN
FORMULARIO DE INSCRIPCIÓN Y MODIFICACIÓN DEL SEGURO DE VIDA