Oregon Large Business Groups
Broker Portfolio Guide
Plan Portfolio Desktopper
Presentation Folder
Note: For example only. Folders can be ordered on CustomPoint
New Group Implementation Forms
- Large Group Application – 2025 – English (PDF)
- Large Group Application – 2025 – En Español (Spanish) (PDF)
- Large Group Application – 2024 – English (PDF)
- Large Group Enrollment Census – 2024 (XLSX)
- Large Group Census Enrollment Guide – English (PDF)
- Electronic Check Form – Binder Payment – English (PDF)
Employee Enrollment and Change Forms
- Employee Enrollment and Change Form – 2025 – English (PDF)
- Employee Enrollment and Change Form – 2025 – En Español (Spanish) (PDF)
- Employee Enrollment and Change Form – 2024 – English (PDF)
- Employee Enrollment and Change Form – 2024 – En Español (Spanish) (PDF)
Pharmacy
This kit is for members only and may not be included in Open Enrollment Kits.
- Getting Started With Mail Order Pharmacy Kit – English (PDF)
- Getting Started With Mail Order Pharmacy Kit – En Español (Spanish) (PDF)
Pharmacy Reimbursement Form
Continuation of Coverage Forms
- Federal Continuation Election Form – COBRA – English (PDF)
- Federal Continuation Election Form – COBRA – En Español (Spanish) (PDF)
HIPAA Disclosures
- Employer Group Health Plan HIPAA Disclosure Directive (PDF)
- Authorization to Use and Disclose Health Information (PDF)
- Revocation of Authorization to Use and/or Disclose Health Information (PDF)
- Request to Access (See) Records (PDF)
Additional Forms and Materials
CommunityCare 1T Plans
Combined medical and pharmacy out-of-pocket maximum.
CommunityCare 3T Plans
Combined medical and pharmacy out-of-pocket maximum.
- 3T CC3T10-500-2-4500DX (PDF)
- 3T CC3T20-2000-2-6000DX (PDF)
- 3T CC3T20-2000-3-6000ES (PDF)
- 3T CC3T35-5000-3-7350ES (PDF)
- 3T CC3T50-7000-3-8150ES (PDF)
PPO Essentials First Dollar Plans
Combined medical and pharmacy out-of-pocket maximum.
- FE25-1000-2-5000 (PDF)
- FE25-1500-2-7350 (PDF)
- FE30-2000-2-7350 (PDF)
- FE35-3000-2-7350 (PDF)
- FE35-5000-2-7350 (PDF)
- FE50-5000-5-8150 (PDF)
PPO Essentials Plans
Combined medical and pharmacy out-of-pocket maximum.
- E25-1000-2-5000 (PDF)
- E30-2000-2-6600 (PDF)
- E35-3000-2-7350 (PDF)
- E35-4000-2-7350 (PDF)
- E35-5000-3-8150 (PDF)
- E35-6000-3-8150 (PDF)
- E50-5000-5-8150 (PDF)
PPO Advantage Plans
Combined medical and pharmacy out-of-pocket maximum.
- LX10-0-2-4000 (PDF)
- A15-250-2-4000 (PDF)
- A20-500-2-4000 (PDF)
- A20-750-2-5000 (PDF)
- A25-1000-2-5000 (PDF)
- A30-1500-2-6600 (PDF)
- A20-2000-2-6600 (PDF)
- A30-2500-3-6600 (PDF)
- A30-3000-2-7350 (PDF)
- A35-3000-3-7350 (PDF)
- A35-5000-2-7350 (PDF)
- A35-5000-3-7350 (PDF)
- E20-500-2-4000 (PDF)
PPO Primary Advantage Plans
Combined medical and pharmacy out-of-pocket maximum.
High Deductible Health Plans
CommunityCare 1T Plans
Combined medical and pharmacy out-of-pocket maximum.
- 1T CC1T20-2000-3-6000ES-KKZ – English (PDF)
- 1T CC1T25-3000-3-7350ES-KL0 – English (PDF)
- 1T CC1T35-3000-3-7350ES-KL1 – English (PDF)
- 1T CC1T35-5000-3-7350ES-KL2 – English (PDF)
CommunityCare 3T Plans
Combined medical and pharmacy out-of-pocket maximum.
- 3T CC3T10-500-2-4500DX-KL3 – English (PDF)
- 3T CC3T15-1000-2-5500DX-KL5 – English (PDF)
- 3T CC3T10-1500-2-5500DX-KL4 – English (PDF)
- 3T CC3T20-2000-2-6000DX-KL6 – English (PDF)
- 3T CC3T20-2000-3-6000ES-KL7 – English (PDF)
- 3T CC3T25-3000-2-7350DX-KL8 – English (PDF)
- 3T CC3T35-3000-3-7350ES-KL9 – English (PDF)
- 3T CC3T35-5000-3-7350ES-KLB – English (PDF)
- 3T CC3T50-7000-3-8150ES-KLC – English (PDF)
PPO Essentials First Dollar Plans
Combined medical and pharmacy out-of-pocket maximum.
- FE25-1000-2-5000-KNB – English (PDF)
- FE25-1500-2-7350-KNC – English (PDF)
- FE30-2000-2-7350-KND – English (PDF)
- FE35-3000-2-7350-KNE – English (PDF)
- FE35-3000-2-7350-KNE – En Español (Spanish) (PDF)
- FE35-5000-2-7350-KNF – English (PDF)
- FE50-5000-5-7350-KNG – English (PDF)
- FE50-5000-5-7350-KNG – En Español (Spanish) (PDF)
PPO Essentials Plans
Combined medical and pharmacy out-of-pocket maximum.
- E25-1000-2-5000-KN1 – English (PDF)
- E25-1000-2-5000-KN1 – En Español (Spanish) (PDF)
- E30-2000-2-6600-KN2 – English (PDF)
- E35-3000-2-7350-KN3 – English (PDF)
- E35-3000-2-7350-KN3 – En Español (Spanish) (PDF)
- E35-4000-2-7350-KN4 – English (PDF)
- E35-5000-3-8150-KN5 – English (PDF)
- E35-5000-3-8150-KN5 – En Español (Spanish) (PDF)
- E35-6000-3-8150-KN6 – English (PDF)
- E35-6000-3-8150-KN6 – En Español (Spanish) (PDF)
- E50-3000-5-7350-KN7 – English (PDF)
- E50-5000-5-7350-KN8 – English (PDF)
- E50-5000-5-7350-KN8 – En Español (Spanish) (PDF)
- E50-6000-5-8150-KN9 – English (PDF)
- E50-6000-5-8150-KN9 – En Español (Spanish) (PDF)
- E20-500-2-4000-KN0 – English (PDF)
PPO Advantage Plans
Combined medical and pharmacy out-of-pocket maximum.
- LX10-0-2-4000-KMM – English (PDF)
- A15-250-2-4000-KMO – English (PDF)
- A20-500-2-4000-KMQ – English (PDF)
- A20-500-2-4000-KMQ – En Español (Spanish) (PDF)
- A20-750-2-5000-KMR – English (PDF)
- A25-1000-2-5000-KMT – English (PDF)
- A30-1500-2-6600-KMU – English (PDF)
- A20-2000-2-6600-KMS – English (PDF)
- A20-2000-2-6600-KMS – En Español (Spanish) (PDF)
- A30-2500-3-6600-KMV – English (PDF)
- A30-3000-2-7350-KMW – English (PDF)
- A35-3000-3-7350-KMX – English (PDF)
- A35-5000-2-7350-KMY – English (PDF)
- A35-5000-3-7350-KMZ – English (PDF)
PPO Primary Advantage Plans
Combined medical and pharmacy out-of-pocket maximum.
- PA0-500-4-5000-KML – English (PDF)
- PA10-3000-5-7350-KMN – English (PDF)
- PA20-5000-5-7350-KMP – English (PDF)
High Deductible Health Plans
Alternative Care
Vision
- Elite 1010-1 – English (PDF)
- Elite 1010-1 – En Español (Spanish) (PDF)
- Preferred 1025-2 – English (PDF)
- Preferred 1025-2 – En Español (Spanish) (PDF)
- Preferred 1025-3 – English (PDF)
- Plus 20-1 – English (PDF)
- Preferred Value 10-3 – English (PDF)
- Supreme 010-2 – English (PDF)
- Exam Only Plan – English (PDF)
Dental
- Essential D50-16-500 – English (PDF)
- Fifty D100-555-1000V – English (PDF)
- Plus D25-185-1500 – English (PDF)
- Plus D25-1855-1500 – English (PDF)
- Plus D25-1855-2000 – English (PDF)
- Plus D50-185-1000 – English (PDF)
- Plus D50-185-1500 – English (PDF)
- Plus D50-185-2000 – English (PDF)
- Plus D50-1855-1500 – English (PDF)
- Plus D50-1855-2000 – English (PDF)
- Plus D100-185-1000 – English (PDF)
- Plus D100-185-1500 – English (PDF)
- Plus D100-185-2000 – English (PDF)
- Plus D100-1855-1000 – English (PDF)
- Plus D100-1855-2000 – English (PDF)
- Preferred Plus DP50-1855-1500 – English (PDF)
- Preferred Value DP100-185-1000V – English (PDF)
- Value D50-185-1500V – English (PDF)
- Value D100-185-1000V – English (PDF)
Pharmacy Rx
Prescription Drug Riders No MAC
Combined medical and pharmacy out-of-pocket maximum.
- NMSL10-20-40 – English (PDF)
- NMSL5-10-25 – English (PDF)
- NMSL10-35-60 – English (PDF)
- NMSL10-50-75 – English (PDF)
- NMSL15-30-50 – English (PDF)
- NMSL15-40-65 – English (PDF)
- NMSL15-30%-50% – English (PDF)
Prescription Drug Riders No MAC with deductible
Combined medical and pharmacy out-of-pocket maximum.
Prescription Drug Riders MAC A
Combined medical and pharmacy out-of-pocket maximum.
- MASL10-10-DR (MAC A) – English (PDF)
- MASL10-20%-DR (MAC A) – English (PDF)
- MASL15-50%-DR (MAC A) – English (PDF)
- MASL25-50%-DR (MAC A) – English (PDF)
Prescription Drug Riders High Deductible Health Plans (HSA)
Combined medical and pharmacy out-of-pocket maximum.
Alternative Care
Vision
- Elite 1010-1 – English (PDF)
- Elite 1010-1 – En Español (Spanish) (PDF)
- Supreme 010-2 – English (PDF)
- Preferred 1025-2 – English (PDF)
- Preferred 1025-2 – En Español (Spanish) (PDF)
- Preferred 1025-3 – English (PDF)
- Preferred Value 10-3 – English (PDF)
- Plus 20-1 – English (PDF)
- Exam Only – English (PDF)
Dental
- Essential D50-16-500 – English (PDF)
- Fifty D100-555-1000V – English (PDF)
- Plus D25-185-1500 – English (PDF)
- Plus D25-1855-1500 – English (PDF)
- Plus D25-1855-2000 – English (PDF)
- Plus D50-185-1000 – English (PDF)
- Plus D50-185-1500 – English (PDF)
- Plus D50-185-2000 – English (PDF)
- Plus D50-1855-1500 – English (PDF)
- Plus D50-1855-2000 – English (PDF)
- Plus D100-185-1000 – English (PDF)
- Plus D100-185-1500 – English (PDF)
- Plus D100-185-2000 – English (PDF)
- Plus D100-1855-1000 – English (PDF)
- Plus D100-1855-2000 – English (PDF)
- Preferred Plus DP50-1855-1500 – English (PDF)
- Preferred Value DP100-185-1000V – English (PDF)
- Value D50-185-1500V – English (PDF)
- Value D100-185-1000V – English (PDF)
Pharmacy Rx
Prescription Drug Riders No MAC
Combined medical and pharmacy out-of-pocket maximum.
- NMSL5-10-25 – English (PDF)
- NMSL10-20-40 – English (PDF)
- NMSL10-35-60 – English (PDF)
- NMSL10-35-60 – En Español (Spanish) (PDF)
- NMSL10-50-75 – English (PDF)
- NMSL10-50-75 – En Español (Spanish) (PDF)
- NMSL15-30-50 – English (PDF)
- NMSL15-40-65 – English (PDF)
- NMSL15-30%-50% – English (PDF)
Prescription Drug Riders No MAC with deductible
Combined medical and pharmacy out-of-pocket maximum.
Prescription Drug Riders MAC A
Combined medical and pharmacy out-of-pocket maximum.
- MASL10-10-DR – English (PDF)
- MASL10-20%-DR – English (PDF)
- MASL15-50%-DR – English (PDF)
- MASL15-50%-DR – En Español (Spanish) (PDF)
- MASL25-50%-DR – English (PDF)
Prescription Drug Riders High Deductible Health Plans (HSA)
Combined medical and pharmacy out-of-pocket maximum.
SBC Distribution Information
The PDF below provides detailed instructions for distribution and reproduction of the Summary of Benefits and Coverage (SBC) document, as required under the Affordable Care Act.
- Summary of Benefits and Coverage (SBC) Employer Group Instructions Sheet (PDF)
- SBC Online Lookup Tool Instructions (PDF)
CommunityCare
Additional Tools
- Member Quick Start Guide – English (PDF)
- Member Quick Start Guide – En Español (Spanish) (PDF)
- Health Net Value-Add Programs Flyer – English (PDF)
- Health Net Value-Add Programs Flyer – En Español (Spanish) (PDF)
- Teladoc Member FAQs (PDF)
- You've Got Teladoc Health (PDF)
- Teladoc – Your Path Toward Mental Well-Being (PDF)
- EFT Set Up Instructions (PDF)
- How To Read Your Commission Statement (PDF)
- Same Day Care – English (PDF)
- Same Day Care – En Español (Spanish) (PDF)
- Coordination of Benefits for Members (PDF)
- Generic vs Brand-Name Drugs Information (PDF)
- Employer Online Enrollment and Billing (PDF)
- First Health Network FAQs (PDF)
- Dental Website Overview (PDF)
- Vision Website Overview (PDF)
- Employer Portal Registration (PDF)
- Behavioral Health FAQs – English (PDF)
- Behavioral Health FAQs – En Español (Spanish) (PDF)
- Health Net Website Flyer (PDF)
- Find a Provider Flyer (PDF)
Uniform Glossary of Health Coverage and Medical Terms
Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer, understand some of the most common language used in health insurance documents. Please log in to request a hard copy of the document by mail.
- Uniform Glossary of Health Coverage and Medical Terms – English (PDF)
- Uniform Glossary of Health Coverage and Medical Terms – En Español (Spanish) (PDF)
- Uniform Glossary of Health Coverage and Medical Terms – Chinese (PDF)
- Uniform Glossary of Health Coverage and Medical Terms – Navajo (PDF)
- Uniform Glossary of Health Coverage and Medical Terms – Korean (PDF)
- Healthy Discounts Booklet (PDF)
- Health and Wellness Brochure (PDF)
- Preventive Care and Screenings (Facts about ACA-Covered Services) – English (PDF)
- Preventive Care and Screenings (Facts about ACA-Covered Services) – En Español (Spanish) (PDF)
- Active&Fit™ Direct Program Flyer (PDF)
- How to Register for Sharecare (PDF)
- Sharecare FAQs (PDF)
- Sharecare Unwinding Program Flyer (PDF)
- Sharecare Unwinding Program FAQs (PDF)
- RealAge Program (PDF)
- RealAge Program FAQs (PDF)
- Eat Right Now Program Flyer (PDF)
- Eat Right Now FAQs (PDF)
- Craving to Quit Flyer (PDF)
- Craving to Quit FAQs (PDF)
- Health Coaching (Lifestyle Management) Flyer (PDF)
- Health Coaching (Lifestyle Management) FAQs (PDF)