Washington Large Business Groups
Broker Portfolio Guide
Employer Group Application
Enrollment and Change Applications
- Employee Enrollment and Change Form - 2020 - English (PDF)
- Employee Enrollment and Change Form - 2020 - Spanish (PDF)
- Employee Enrollment and Change Form - 2019 - English (PDF)
- Employee Enrollment and Change Form - 2019 - 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)
Additional Forms and Materials
- Enhanced Choice/CommunityCare Request Form (PDF)
- Disabled Dependent Certification (PDF)
- Member Reimbursement Claim Form (PDF)
- Wellness PayBack Claim Form (PDF)
- Sold Group Checklist Form (PDF)
- Coordination of Benefits Form (PDF)
- Provider Nomination Form (PDF)
- Washington Eligibility/Enrollment Inquiry (PDF)
PPO Advantage LX Plans
Combined medical and pharmacy out-of-pocket maximum.
PPO Advantage DX Plans
Combined medical and pharmacy out-of-pocket maximum.
- WA15-250-1-3500D (PDF)
- WA20-500-2-3500D (PDF)
- WA25-250-2-3500D (PDF)
- WA25-750-2-3500D (PDF)
- WA25-1000-2-5000D (PDF)
- WA25-1500-2-5000D (PDF)
- WA25-2000-2-5000D (PDF)
- WA25-2000-2-6500D (PDF)
- WA35-1000-2-5000D (PDF)
- WA35-1500-2-6500D (PDF)
- WA35-2000-2-6500D (PDF)
- WA35-3000-2-6500D (PDF)
- WA35-5000-2-6500D (PDF)
PPO Advantage Value Plans
Combined medical and pharmacy out-of-pocket maximum.
- WA25-500-2-5000V (PDF)
- WA25-750-2-5000V (PDF)
- WA25-1000-2-5000V (PDF)
- WA25-1500-2-5000VA (PDF)
- WA25-2000-2-5000V (PDF)
- WA35-1000-2-6500V (PDF)
- WA35-1500-2-6500V (PDF)
- WA35-2000-2-6500V (PDF)
- WA35-3000-3-6500V (PDF)
- WA40-6000-3-6500V (PDF)
- WA35-5000-3-8150V (PDF)
- WA50-7000-3-8150V (PDF)
PPO Advantage Value Options Plans
PPO High-Deductible Health Plans
Pharmacy Plan Overviews
- WNM5-25-50 (PDF)
- WNM10-20-40 (PDF)
- WNM10-50-75 (PDF)
- WNM15-30-50 (PDF)
- WNM15-35-60 (PDF)
- WNM15-30%-50% (PDF)
- WNM10-35-50-250D (PDF)
- WNM15-40-75-250D (PDF)
- WNM15-30%-50%-250D (PDF)
PPO Vision Plan Overviews
PPO Advantage LX Plans
Combined medical and pharmacy out-of-pocket maximum.
PPO Advantage DX Plans
Combined medical and pharmacy out-of-pocket maximum.
PPO Advantage Value Plans
Combined medical and pharmacy out-of-pocket maximum.
PPO Advantage Value Options Plans
Combined medical and pharmacy out-of-pocket maximum.
PPO High-Deductible Health Plans
Pharmacy Plan Overviews
Combined medical and pharmacy out-of-pocket maximum.
PPO Vision Plan Overviews
Health Care Reform
PDF provides detailed instructions for distribution and reproduction of the Summary of Benefits and Coverage form required under the Affordable Care Act.
Additional Tools
- Teladoc Member FAQs (PDF)
- Think of Teladoc First (PDF)
- Teladoc Mental Health - Getting Started (PDF)
- Sales Guidelines (PDF)
- Active&Fit Direct Member Flyer - English (PDF)
- Active&Fit Direct Member Flyer - Spanish (PDF)
- EFT Set Up Instructions (PDF)
- How To Read Your Commission Statement (PDF)
- Top Reasons to Sell Health Net (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 Mobile App How-To - English (PDF)
- Health Net Mobile App How-To - Spanish (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)