Group Member Forms and Brochures

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

For members on Health Net Health Plan of Oregon, Inc. plans (PDF)

• Coordination of Benefits Form (PDF)
• Out-of-Network Vision Claim Form (PDF)
• Wellness PayBack Claim Form (PDF)

Complete the claim form for each member submitting bills for reimbursement of covered services. To avoid any delay, be sure to answer each question completely. Please attach fully itemized bills and proof of payment.

Medical Claim Reimbursement Form – English (PDF)

Small Group

• Small Business Group Employee Enrollment and Change Form – 2023 – English (PDF)
• Small Business Group Employee Enrollment and Change Form – 2023 – En Español (Spanish) (PDF)
• Small Business Group Employee Enrollment and Change Form – 2022 – English (PDF)
• Small Business Group Employee Enrollment and Change Form – 2022 – En Español (Spanish) (PDF)

Large Group

• Large Business Group Employee Enrollment and Change Form – 2023 – English (PDF)
• Large Business Group Employee Enrollment and Change Form – 2023 – En Español (Spanish) (PDF)
• Large Business Group Employee Enrollment and Change Form – 2022 – English (PDF)
• Large Business Group Employee Enrollment and Change Form – 2022 – En Español (Spanish) (PDF)

Additional forms

• Oregon State Continuation Election Form – 2023 – English (PDF)

• Oregon Supplemental Dependent Enrollment and Change Form – English (PDF)
• Disabled Dependent Certification – English (PDF)

• Member Handbook (PDF)
• Continuity of Care Instructions (PDF)
• Same Day Care (PDF)
• Teladoc Member FAQs (PDF)
• Think of Teladoc First (PDF)
• Teladoc Mental Health – Getting Started (PDF)
• Behavioral Health/MHN FAQs (PDF)
• Health Net Website Flyer (PDF)

Mail Order Pharmacy

Getting Started With Mail Order Pharmacy Kit

CVS Caremark Mail Order Pharmacy

• CVS Caremark Mail Order – English (PDF)
• CVS Caremark Mail Order – En Español (Spanish) (PDF)

Medication Therapy Management

• Personal Medication List (PDF)

Prescription Claims

• Prescription Claim Form – Commercial Members (PDF)
• Prescription Claim Form – Medicare Members (PDF)

Approved Drug Lists

The drug list, or formulary, is a list of covered drugs selected by Health Net, along with a team of health care providers. These drugs are selected because they are believed to be a necessary part of a quality treatment program. Our drug lists are updated regularly and are subject to change.

Essential Health Benefit Drug Lists for Group Plans:

• Oregon Essential Prescription Drug List (PDF)
• Washington Essential Prescription Drug List (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)

• 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)

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.

• Glossary of Health Coverage and Medical Terms – English (PDF)
• Glossary of Health Coverage and Medical Terms – Spanish (PDF)
• Glossary of Health Coverage and Medical Terms – Chinese (PDF)
• Glossary of Health Coverage and Medical Terms – Navajo (PDF)
• Glossary of Health Coverage and Medical Terms – Korean (PDF)