Oregon Large Business Groups

Portfolio Plan Desktopper

• Portfolio Plan Desktopper - 2021 (PDF)

Broker Portfolio Guide

• Portfolio Guide - 2021 (PDF)

Employer Group Application

• Large Group Application - 2021 (PDF)

Enrollment and Change Applications

• Employee Enrollment and Change Form - 2021 - English (PDF)
• Employee Enrollment and Change Form - 2021 - Spanish (PDF)
• Employee Enrollment and Change Form - 2020 - English (PDF) 
• Employee Enrollment and Change Form - 2020 - 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 - Spanish (PDF)

Pharmacy Reimbursement Form

Pharmacy Reimbursement Form (PDF)

Continuation of Coverage Forms

• Federal Continuation Election Form - COBRA - English (PDF)
• Federal Continuation Election Form - COBRA - 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)
  

Additional Forms and Materials

• Enhanced Choice/CommunityCare Request Form (PDF)
• Disabled Dependent Certification (PDF)
• Member Reimbursement Claim Form (PDF)
• Wellness PayBack Claim Form (PDF)
• Coordination of Benefits Form (PDF)
• Oregon Group Profile Form (PDF)
• Provider Nomination Form (PDF)

CommunityCare 1T Plans

Combined medical and pharmacy out-of-pocket maximum.

• CC1T10-500-2-4500DX (PDF)
• CC1T10-1500-2-5500DX (PDF)
• CC1T15-1000-2-5500DX (PDF)
• CC1T20-2000-2-6000DX (PDF)
• CC1T20-2000-3-6000ES (PDF)
• CC1T25-3000-2-7350DX (PDF)
• CC1T35-3000-3-7350ES (PDF)
• CC1T35-5000-3-7350ES (PDF)
• CC1T50-5000-3-7350ES (PDF)
• CC1T50-7000-3-8150ES (PDF)

CommunityCare 1T High Deductible Health Plans

Combined medical and pharmacy out-of-pocket maximum.

• HDECC1T25-3000-2-6600 (PDF)
• HDECC1T35-3000-3-6750 (PDF)
• HDECC1T35-5000-2-6600 (PDF)
• HDECC1T35-5000-3-6600 (PDF)
  

CommunityCare 3T Plans

Combined medical and pharmacy out-of-pocket maximum.

• CC3T10-0-2-4500DX (PDF)
• CC3T10-500-2-4500DX (PDF)
• CC3T10-750-2-500DX (PDF)
• CC3T10-1500-2-5500DX (PDF)
• CC3T15-1000-2-5500DX (PDF)
• CC3T15-1000-3-5500ES (PDF)
• CC3T20-2000-2-6000DX (PDF)
• CC3T20-2000-3-6000ES (PDF)
• CC3T25-3000-2-7350DX (PDF)
• CC3T25-3000-3-7350ES (PDF)
• CC3T35-3000-3-7350ES (PDF)
• CC3T35-5000-3-7350ES (PDF)
• CC3T50-5000-3-7350ES (PDF)
• CC3T50-7000-3-8150ES (PDF)

CommunityCare 3T High Deductible Health Plans

Combined medical and pharmacy out-of-pocket maximum.

• HDECC3T25-3000-2-6600 (PDF)
• HDECC3T25-3000-3-6600 (PDF)
• HDECC3T35-5000-2-6600 (PDF)
• HDECC3T35-5000-3-6600 (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)
• FE50-5000-5-7350 (PDF)
• FE5000-3-8150 (PDF)
• FE50/50-3500 (PDF)
• FE50/50-5000 (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)
• E35-5000-2-7350 (PDF)
• E35-6000-2-7350 (PDF)
• E50-3000-5-7350 (PDF)
• E50-5000-5-7350 (PDF)
• E50-6000-5-8150 (PDF)
• E5000-3-7350 (PDF)
• E5000-5-7350 (PDF)
• E6000-5-8150 (PDF)
• E7000-3-8150 (PDF)
• E7000-5-8150 (PDF)

PPO Advantage Plans

Combined medical and pharmacy out-of-pocket maximum.

• A15-250-2-4000 (PDF)
• A20-500-2-4000 (PDF)
• A20-750-2-5000 (PDF)
• A20-1000-2-5000 (PDF)
• A25-1000-2-5000 (PDF)
• A20-2000-2-6600 (PDF)
• A30-1500-2-6600 (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)
• V20-500-2-4000 (PDF)
• V25-1000-2-5000 (PDF)
• V30-2000-2-6000 (PDF)
• V35-4000-2-7350 (PDF)
• V35-5000-2-7350 (PDF)
• V40-6000-2-8150 (PDF)
• LX20-500-2-4000 (PDF)
• LX25-1000-2-5000 (PDF)

PPO Primary Advantage Plans

Combined medical and pharmacy out-of-pocket maximum.

• PA0-0-4-2500 (PDF)
• PA0-500-4-5000 (PDF)
• PA0-1000-4-5000 (PDF)
• PA10-3000-5-7350 (PDF)
• PA20-5000-5-7350 (PDF)

PPO Fifty Plans

Combined medical and pharmacy out-of-pocket maximum.

• 50/50-2500 (PDF)
• 50/50-3500 (PDF)
• 50/50-5000 (PDF)
  

High Deductible Health Plans

• HDE28008060 & HDE56008060 (PDF)
• HDE35008060 & HDE70008060E (PDF)
• HDE50008060 & HDE100008060 (PDF)
• HD300010060 & HD600010060 (PDF)
• HDE650010060 & HDE1300010060 (PDF)

CommunityCare 1T Plans

Combined medical and pharmacy out-of-pocket maximum.

• CC1T10-500-2-4500DX (PDF)
• CC1T10-1500-2-5500DX (PDF)
• CC1T15-1000-2-5500DX (PDF)
• CC1T15-1000-2-6600DX (PDF)
• CC1T20-2000-2-6000DX (PDF)
• CC1T20-2000-2-6600DX (PDF)
• CC1T25-3000-2-7350DX (PDF)
• CC1T25-3000-3-8150DX (PDF)
• CC1T30-5000-3-8150DX (PDF)
• CC1T20-2000-3-6000ES (PDF)
• CC1T35-3000-3-7350ES (PDF) 
• CC1T35-5000-3-7350ES (PDF)
• CC1T50-5000-3-7350ES (PDF)
• CC1T50-7000-3-8150ES (PDF)
  

CommunityCare 1T High Deductible Health Plans

Combined medical and pharmacy out-of-pocket maximum.

• HDECC1T25-3000-2-6600 (PDF)
• HDECC1T35-3000-3-6750 (PDF)
• HDECC1T35-5000-2-6600 (PDF)
• HDECC1T35-5000-3-6600 (PDF)
  

CommunityCare 3T Plans

Combined medical and pharmacy out-of-pocket maximum.

• CC3T10-0-2-4500DX (PDF)
• CC3T10-500-2-4500DX (PDF)
• CC3T10-750-2-5500DX (PDF)
• CC3T10-1500-2-5500DX (PDF)
• CC3T15-1000-2-5500DX (PDF)
• CC3T20-2000-2-6000DX (PDF)
• CC3T25-3000-2-7350DX (PDF)
• CC3T15-1000-3-5500ES (PDF)
• CC3T20-2000-3-6000ES (PDF)
• CC3T25-3000-3-7350ES (PDF)
• CC3T35-3000-3-7350ES (PDF)
• CC3T35-5000-3-7350ES (PDF)
• CC3T50-5000-3-7350ES (PDF)
• CC3T50-7000-3-8150ES (PDF)
  

CommunityCare 3T High Deductible Health Plans

Combined medical and pharmacy out-of-pocket maximum.

• HDECC3T25-3000-2-6600 (PDF)
• HDECC3T25-3000-3-6600 (PDF)
• HDECC3T35-5000-2-6600 (PDF)
• HDECC3T35-5000-3-6600 (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)
• FE50-50-3500 (PDF)
• FE50-50-5000 (PDF)
• FE50-5000-5-7350 (PDF)
• FE5000-3-8150 (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)
• E35-5000-2-7350 (PDF)
• E50-5000-5-7350 (PDF)
• E5000-3-7350 (PDF)
• E5000-5-7350 (PDF)
• E6000-5-8150 (PDF)
• E7000-3-8150 (PDF)
• E7000-5-8150 (PDF)
  

PPO Advantage Plans

Combined medical and pharmacy out-of-pocket maximum.

• A15-250-2-4000 (PDF)
• A20-500-2-4000 (PDF)
• A20-750-2-5000 (PDF)
• A20-1000-2-5000 (PDF)
• A20-2000-2-6600 (PDF)
• A25-1000-2-5000 (PDF)
• A30-1500-2-6600 (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)
• V20-500-2-4000 (PDF)
• V25-1000-2-5000 (PDF)
• V30-2000-2-6000 (PDF)
• V35-5000-2-7350 (PDF)
• V40-6000-2-8150 (PDF)
  
• LX20-500-2-4000 (PDF)
• LX25-1000-2-5000 (PDF)

PPO Fifty Plans

Combined medical and pharmacy out-of-pocket maximum.

• 50/50-2500 (PDF)
• 50/50-3500 (PDF)
• 50/50-5000 (PDF)
  

High-Deductible Health Plans

• HD3000 6000 100 60 (PDF)
• HDE2800 5600 80 60 (PDF)
• HDE3500 7000 80 60 (PDF)
• HDE5000 10000 80 60 (PDF)
• HDE6500 13000 100 60 (PDF)

Alternative Care

• CAM15-1000 (PDF)
• CAM15-1000 Plus (PDF)
• CAM15-1500 (PDF)
• CAM15-1500 Plus (PDF)

Vision

• Elite 1010-1 (PDF)
• Supreme 010-2 (PDF)
• Preferred 1025-2 (PDF)
• Preferred 1025-3 (PDF)
• Preferred Value 10-3 (PDF)
• Plus 20-1 (PDF)
• Exam Only (PDF)

Dental

• Essentials D50-16-500 (PDF)
• Fifty D100-555-1000V (PDF)
• Plus D25-185-1500 (PDF)
• Plus D25-1855-1500 (PDF)
• Plus D25-1855-2000 (PDF)
• Plus D50-185-1000 (PDF)
• Plus D50-185-1500 (PDF)
• Plus D50-185-2000 (PDF)
• Plus D50-1855-1500 (PDF)
• Plus D50-1855-2000 (PDF)
• Plus D100-185-1000 (PDF)
• Plus D100-185-1500 (PDF)
• Plus D100-185-2000 (PDF)
• Plus D100-1855-1000 (PDF)
• Plus D100-1855-2000 (PDF)
• Preferred Plus DP50-1855-1500 (PDF)
• Preferred Value DP100-185-1000V (PDF)
• Value D50-185-1500V (PDF)
• Value D100-185-1000V (PDF)

Pharmacy Rx

Prescription Drug Riders No MAC

Combined medical and pharmacy out-of-pocket maximum.

• NMSL5-10-25 (PDF)
• NMSL10-20-40 (PDF)
• NMSL10-35-60 (PDF)
• NMSL10-50-75 (PDF)
• NMSL15-30-50 (PDF)
• NMSL15-40-65 (PDF)
• NMSL15-30%-50% (PDF)
  

Prescription Drug Riders No MAC with deductible

Combined medical and pharmacy out-of-pocket maximum.

• NMSL10-35-60-100D (PDF)
• NMSL10-35-60-250D (PDF)
  

Prescription Drug Riders MAC A

Combined medical and pharmacy out-of-pocket maximum.

• MASL10-10-DR (PDF)
• MASL10-20%-DR (PDF)
• MASL15-50%-DR (PDF)
• MASL25-50%-DR (PDF)

Health Care Reform

Preventive Care and Screenings (Facts about ACA-Covered Services) (PDF)

PDF provides detailed instructions for distribution and reproduction of the Summary of Benefits and Coverage form required under the Affordable Care Act.

Summary of Benefits and Coverage (SBC) Employer Group Instructions Sheet (PDF)

CommunityCare

• Health Net CommunityCare (PDF)
• Facts about Health Net CommunityCare for Members (PDF)
• Health Net CommunityCare Wellness Program (PDF)
• Health Net CommunityCare Wellness Rewards Program (PDF)

Additional Tools

• Teladoc Member FAQs (PDF)
• Think of Teladoc First (PDF)
• Teladoc Mental Health - Getting Started (PDF)
• Sales Guidelines (PDF)
• EFT Set Up Instructions (PDF)
• How To Read Your Commission Statement (PDF)
• Top Reasons to Sell Health Net (PDF)
• Member Handbook - 2021 (PDF)
• ER vs. Urgent Care (PDF)
• Coordination of Benefits Flyer (PDF)
• Secure Messaging Reference Guide (PDF)
• Generic vs Brand-Name Drugs Information (PDF)
• Employer Online Enrollment and Billing (PDF)
• National PPO Network (PDF)
• Health Net Website and Mobile App How-To Flyer (PDF)
• Your Dental Website from Health Net (PDF)
• Your Vision Website from Health Net (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 - 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)

Are your clients looking for greater convenience, service and choice in consumer directed health care benefits? We have partnered with HealthEquity for HRA and HSA integration alongside our Large group products. A proven expert in financial arrangement integration and administration, HealthEquity offers easy-to-use tools and comprehensive resources. Our PPO and Community Care high deductible health plans (HDHP’s), can be offered alongside their integrated health savings account (HSA), while all of our PPO plans can be offered with their integrated health reimbursement account (HRA). 

Learn more about HealthEquity HSA & HRA Plans on the HealthEquity website. Go to HealthEquity sales resource site.

• Health and Wellness Program and Services Guide (PDF)
• Online Wellness Programs and Resources (PDF)
• Healthy Discounts Booklet (PDF)
• myStrength (PDF)
• Get to Know the Health Coaching Program (PDF)
• Quit Smoking and Using Tobacco (PDF)
• Ready to Lose Weight? (PDF)
• Health Net’s Preventive Screening Guidelines - English (PDF)
• Health Net's Preventive Screening Guidelines - Spanish (PDF)
• Active&Fit Direct Member Flyer - English (PDF)
• Active&Fit Direct Member Flyer - Spanish (PDF)

• Health and Wellness Program and Services Guide (PDF)
• National Observances 2021 (PDF)
• Free Wellness Webinars 2021 (PDF)