Health Benefit Forms

• CCSF PPO & EPO COORDINATION OF BENEFITS (COB) FORM
• CCSF PPO & EPO GUARANTOR AFFIDAVIT FORM
• CCSF PPO WELLNESS BENEFIT DESIGNATION FORM To Be Submitted To UMR
• HEALTH BENEFIT CHANGE FORM
• HEALTH BENEFITS ENROLLMENT FORM (FILLABLE)
• HEALTH BENEFITS ENROLLMENT FORM (PRINTABLE)

Clark County Self-Funded PPO

***ATTENTION***The Clark County Self-Funded Plan does not guarantee that all services of providers or facilities will be covered under your health care plan. Benefits should be confirmed by contacting UMR at (800) 395-7069. Failure to check this may result in your claims not being reimbursed for certain incurred expenses.

• 2025 CC PPO Summary Benefit Coverage
• 2025 CCSF PPO Plan Document
• CCSF PPO Provider Directory PDF version (Medical Provider Only) [description=Southern Nevada, Northern Nevada, and Mohave County providers]
• CCSF PPO Provider Directory PDF version (Medical Provider Only) [description=Sierra Healthcare Options website link to search Southern Nevada, Northern Nevada, and Mohave County providers]
• CCSF PPO Provider Directory searchable link (Medical Providers Only) [description=Sierra Healthcare Options website link to search Southern Nevada, Northern Nevada, and Mohave County providers]
• Click here to access the 2025 United Healthcare Dental PPO Directory [description=To search for an in-network dental provider, please visit umr.com  Select Find a provider  Choose Dental  Type UnitedHealthcare Dental PPO in the search box or use the alphabetical listing.]
• Commercial Formulary (Clark County Employees & Non-Medicare Retirees Only) *Subject to Change*
• EyeMed Vision Care
• Navitus Health Solutions
• Transparency In Coverage [description=For any questions regarding the link or pricing, please contact UMR Customer Care at 800.395.7069; the number is also listed at the back of your ID card.]
• UMR

Clark County EPO

***ATTENTION***The Clark County Self-Funded Plan does not guarantee that all services of providers or facilities will be covered under your health care plan. Benefits should be confirmed by contacting UMR at (800) 395-7069. Failure to check this may result in your claims not being reimbursed for certain incurred expenses.

• 2025 CC EPO Plan Document
• CC EPO Copayment
• CC EPO Summary Benefit Coverage
• CCSF EPO Provider Directory PDF version (Medical Provider Only) [description=Southern Nevada, Northern Nevada, and Mohave County providers]
• Click here to access the link for CC EPO Dental Providers [description=To search for an in-network dental provider, please visit sierrahealthcareoptions.com]
• Click here to access the link for the CC EPO Medical Provider Directory [description=Visit the Sierra Healthcare Options website to search for Southern Nevada, Northern Nevada, and Mohave County providers.]
• Commercial Formulary (Clark County Employees & Non-Medicare Retirees Only) *Subject to Change*
• EyeMed Vision Care
• Navitus Health Solutions
• UMR

RETIREE PHARMACY BENEFITS INFORMATION EGWP (Medicare Retirees Only) Clark County Self-Funded PPO & Clark County EPO

• EGWP Evidence of Coverage
• EGWP FORMULARY *Subject to Change*
• EGWP Non-Discrimination Statement
• EGWP Pharmacy Directory

Out-of-Area (OOA)

• 2025 United Healthcare Dental PPO Directory [description=To search for an in-network dental provider, please visit umr.com  Select Find a provider  Choose Dental  Type UnitedHealthcare Dental PPO in the search box or use the alphabetical listing.]
• CCSF PPO and EPO Guarantor Affidavit Form
• Click here to access CCSF Out-of-Area Dependents and Retirees - Mental Health Providers
• Click here to access the United Choice Plus CCSF Out-of-Area Dependent and Retirees - Medical Providers
• Teledoc Urgent Care and Mental Health Flyer