Oregon Large Business Groups

Broker Portfolio Guide

• Portfolio Guide - 2023 (PDF)
• Portfolio Guide - 2022 (PDF)

Plan Portfolio Desktopper

• Plan Portfolio Desktopper - 2023 (PDF)
• Plan Portfolio Desktopper - 2022 (PDF)

Employer Group Application

• Large Group Application - 2023 (PDF)
• Large Group Application - 2022 (PDF)

Employee Enrollment and Change Forms

• Employee Enrollment and Change Form - 2023 - English (PDF)
• Employee Enrollment and Change Form - 2023 - En Español (Spanish) (PDF)
• Employee Enrollment and Change Form - 2022 - English (PDF)
• Employee Enrollment and Change Form - 2022 - 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

• Pharmacy Reimbursement Form (PDF)
  

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

• Disabled Dependent Certification (PDF)
• Medical Claim Reimbursement Form & Foreign Claim Questionnaire (PDF)
• Wellness PayBack Claim Form (PDF)
• Coordination of Benefits Form (PDF)
• Provider Nomination Form (PDF)
• First Health Provider Nomination Form (PDF)

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)
• CC1T15-1000-2-5500DX (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)
• CC1T50-7000-3-8150ES (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)
• 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)

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)
• E35-6000-2-8150 (PDF)
• E50-3000-5-7350 (PDF)
• E50-5000-5-7350 (PDF)
• E50-6000-5-8150 (PDF)
• E5000-5-8150 (PDF)
• E6000-5-8150 (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)
• 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)
• 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)

High Deductible Health Plans

• HDE30008060 & HDE60008060 (PDF)
• HDE35008060 & HDE70008060E (PDF)
• HDE50008060 & HDE100008060 (PDF)
• HD300010060 & HD600010060 (PDF)
• HDE650010060 & HDE1300010060 (PDF)

CommunityCare 1T Plans

Combined medical and pharmacy out-of-pocket maximum.

• CC1T10-0-2-4500DX (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.

• 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)

Alternative Care

• Base Plan (PDF)
• Buy-Up Plan 1 with OON (PDF)
• Buy-Up Plan 2 (PDF)
• Buy-Up Plan 3 with OON (PDF)

Alternative Care High Deductible Health Plans (HSA)

• 2023 OR LBG Alt Care Base Plan HDHP (PDF)
• 2023 OR LBG Alt Care 0% Base Plan HDHP (PDF)
• 2023 OR LBG Alt Care 20% Base Plan HDHP (PDF)
• 2023 OR LBG Alt Care 30% Base Plan HDHP (PDF)
• 2023 OR LBG Alt Care 50% Base Plan HDHP (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)

Prescription Drug Riders High Deductible Health Plans (HSA)

Combined medical and pharmacy out-of-pocket maximum

• 2023 OR LBG Rx NMSLHD70 (PDF)
• 2023 OR LBG Rx NMSLHD80 (PDF)
• 2023 OR LBG Rx NMSLHD100 (PDF)

Alternative Care

• Base Plan (PDF)
• Buy-Up Plan 1 with OON (PDF)
• Buy-Up Plan 2 (PDF)
• Buy-Up Plan 3 with OON (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)

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)

CommunityCare

• Health Net CommunityCare (PDF)

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)
• Member Handbook - En Español (Spanish) (PDF)
• Same Day Care (PDF)
• Continuity of Care Instructions (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/MHN FAQs (PDF)
• Health Net Website 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 - 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 Enrollment Fee Promotion Flyer (PDF)
• How to Register for Sharecare (PDF)
• Sharecare FAQs (PDF)
• Earn Green Days Overview (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))

• Health & Wellness Program and Services Guide (PDF)
• 2022 Wellness Webinar Schedule (PDF)