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Health Benefit Forms7 documents

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

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.9 documents

• UMR
  document Header UMR
• Transparency In Coverage
  document Header Transparency In Coverage
  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.  
• Navitus Health Solutions
  document Header Navitus Health Solutions
• EyeMed Vision Care
  document Header EyeMed Vision Care
• Commercial Formulary (Clark County Employees & Non-Medicare Retirees Only) *Subject to Change*
  document Header Commercial Formulary (Clark County Employees & Non-Medicare Retirees Only) *Subject to Change*
• CCSF PPO Provider Directory
  document Header CCSF PPO Provider Directory
• CCSF PPO Dental Providers
  document Header CCSF PPO Dental Providers
• 2024 CCSF PPO Plan Document
  document Header 2024 CCSF PPO Plan Document

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.9 documents

• UMR
  document Header UMR
• Navitus Health Solutions
  document Header Navitus Health Solutions
• EyeMed Vision Care
  document Header EyeMed Vision Care
• Commercial Formulary (Clark County Employees & Non-Medicare Retirees Only) *Subject to Change*
  document Header Commercial Formulary (Clark County Employees & Non-Medicare Retirees Only) *Subject to Change*
• CC EPO Summary Benefit Coverage
  document Header CC EPO Summary Benefit Coverage
• CC EPO Provider Directory
  document Header CC EPO Provider Directory
• CC EPO Dental Providers
  document Header CC EPO Dental Providers
• CC EPO Copayment
  document Header CC EPO Copayment
• 2024 CC EPO Plan Document
  document Header 2024 CC EPO Plan Document

RETIREE PHARMACY BENEFITS INFORMATION EGWP (Medicare Retirees Only)                                          Clark County Self-Funded PPO & Clark County EPO                                                                                                                 4 documents

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

Out-of-Area (OOA)

***ATTENTION***Clark County Self-Funded PPO allows eligible dependent(s) and retirees residing outside the State of Nevada 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 on a full-time basis access to the United Healthcare Choice Plus Network with approval and required documentation.  CCSF PPO and EPO allows eligible employees and dependent(s) access to the United Healthcare Choice Plus Network in the event of urgent or emergent services only when traveling outside of the State of Nevada.6 documents

• Teledoc Urgent Care and Mental Health Flyer
  document Header Teledoc Urgent Care and Mental Health Flyer
• Diversified Dental Network
  document Header Diversified Dental Network
• CCSF PPO and EPO Guarantor Affidavit Form
  document Header CCSF PPO and EPO Guarantor Affidavit Form
• CCSF Out-of-Area Dependents and Retirees - Mental Health Providers
  document Header CCSF Out-of-Area Dependents and Retirees - Mental Health Providers
• CCSF Out-of-Area Dependent and Retirees - Medical Providers
  document Header CCSF Out-of-Area Dependent and Retirees - Medical Providers