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Documents, Forms and Legal Notices


​​2025 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​​​​
​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