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]
• Click here to access the link for the CCSF PPO Medical Provider Directory[description=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 the CC EPO Medical Provider Directory[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]
• 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)

***ATTENTION***Clark County Self-Funded PPO allows eligible dependent(s) and retirees residing outside the Sierra Healthcare Options PPO Network access to the United Healthcare Choice Plus Network with approval and required documentation. Clark County EPO allows eligible dependent(s) ages 17-26 attending an accredited university, college, or trade school (full-time) outside of the Sierra Health Care Options PPO Network to obtain access to the United Healthcare Choice Plus Network with approval and required documentation. In the event of urgent/emergent services both Clark County PPO and EPO plans allows plan participants access to the United Healthcare Choice Plus Network when traveling outside of the State of Nevada.

• 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 Network, Dependents and Retirees - Mental Health Providers[description= Scroll down to Addition Resources then Select View Providers.]
• Click here to access the United Choice Plus Out-of-Area Network, Dependents and Retirees - Medical Providers[description= Scroll down to Addition Resources then Select View Providers.]
• EyeMed Vision Care
• Teledoc Urgent Care and Mental Health Flyer