Oregon Large Business Groups
Broker Portfolio Guide
Plan Portfolio Desktopper
Employer Group Application
Employee Enrollment and Change Forms
- Employee Enrollment and Change Form - 2022 - English (PDF)
- Employee Enrollment and Change Form - 2022 - Spanish (PDF)
- Employee Enrollment and Change Form - 2021 - English (PDF)
- Employee Enrollment and Change Form - 2021 - 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
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)
- Request to Access (See) Records (PDF)
Additional Forms and Materials
CommunityCare 1T Plans
Combined medical and pharmacy out-of-pocket maximum.
- CC1T10-0-2-4500DX (PDF)
- CC1T10-500-2-4500DX (PDF)
- CC1T10-750-2-5500DX (PDF)
- CC1T10-1500-2-5500DX (PDF)
- CC1T15-1000-2-5500D (PDF)
- CC1T15-1000-3-5500ES (PDF)
- CC1T20-2000-2-6000DX (PDF)
- CC1T20-2000-3-6000ES (PDF)
- CC1T25-3000-2-7350DX (PDF)
- CC1T25-3000-3-7350ES (PDF)
- CC1T35-3000-3-7350ES (PDF)
- CC1T35-5000-3-7350ES (PDF)
- CC1T50-5000-3-7350ES (PDF)
- CC1T50-7000-3-8150E (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)
- CC3T15-1000-2-5500DS (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 (PDX)
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)
- E70000-5-8150 (PDF)
PPO Advantage Plans
Combined medical and pharmacy out-of-pocket maximum.
- A10-0-2-4000 (PDF)
- A15-250-2-4000 (PDF)
- A20-500-2-4000 (PDF)
- A20-750-2-5000 (PDF)
- A25-1000-2-5000 (PDF)
- A20-1000-2-500 (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)
- V30-20000-2-6000 (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.
- PA0-4-2500 (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.
High Deductible Health Plans
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.
High Deductible Health Plans
Alternative Care
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.
Prescription Drug Riders MAC A
Combined medical and pharmacy out-of-pocket maximum.
Alternative Care
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.
Prescription Drug Riders MAC A
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.
CommunityCare
Additional Tools
- Teladoc Member FAQs (PDF)
- Think of Teladoc First (PDF)
- Teladoc Mental Health - Getting Started (PDF)
- EFT Set Up Instructions (PDF)
- How To Read Your Commission Statement (PDF)
- Member Handbook (PDF)
- Urgent Care vs. ER (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)
- Health Net Website and Mobile App How-To Flyer (PDF)
- Dental Website Overview (PDF)
- Vision Website Overview (PDF)
- Employer Portal Registration (PDF)
- Health Net Received Two National Customer Service Awards (PDF)
- Behavioral Health/MHN FAQs (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 & Wellness Program and Services Guide (PDF)
- Healthy Discounts Booklet (PDF)
- 2022 Wellness Webinar Schedule (PDF)
- myStrength Flyer (PDF)
- Health Net’s Preventive Screening Guidelines - English (PDF)
- Health Net's Preventive Screening Guidelines - Spanish (PDF)
- Preventive Care and Screenings (Facts about ACA-Covered Services) (PDF)
- Active&Fit Direct Member Flyer - English (PDF)
- Active&Fit Direct Member Flyer - Spanish (PDF)
- How to Register for Sharecare (PDF)
- Sharecare FAQs (PDF)
- Earn Green Days Overview (PDF)
- RealAge Program (PDF)
- RealAge Program FAQs (PDF)