Skip to Main Content

Forms & Brochures – Large Business Group Plans

How to View/Download Files

To view or download a file, click the desired language link. The PDF file will open in a new window or tab of your browser. From there, you can also download or print the file.

2024 – Enrollment and Change Applications

2023 – Enrollment and Change Applications

2022 – Enrollment and Change Applications

Group Service Agreement/Policy Applications

Claims

Transition of Care

Dental and Vision Add-On or Change Form

Dental and Vision Add-On or Change Form – English (PDF)

Health Net Life Insurance Forms

Broker and Employer Forms

HIPAA Disclosures

Sales Support Tools

SmartCare

Care Access

National PPO Network (Out-of-State PPO)

Additional Member/Prospect Materials

Behavioral Health

Employer Materials

Glossaries

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.

Travel Guides

Claim forms can also be found under the Applications and Forms section on this page.

Claim forms can also be found under the Applications and Forms section on this page.

Additional Materials

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 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.

Full Network HMO

ExcelCare HMO

SmartCare HMO

Salud HMO y Más

Salud HMO y Más – Facility Deductible

Salud Mexico

CanopyCare HMO

CanopyCare HMO – Facility Deductible

Full Network EOA

Full Network EOA – Facility Deductible

ExcelCare EOA

ExcelCare EOA – Facility Deductible

PPO

PPO (HSA-compatible) (Includes pre-set pharmacy plans)

Pharmacy HMO

(combined medical and pharmacy OOPM)

Pharmacy POS – Elect Open Access (EOA)/ExcelCare EOA

Pharmacy HMO – Salud HMO y Más

(combined medical and pharmacy OOPM)

CanopyCare HMO

Pharmacy PPO

(combined medical and pharmacy OOPM)

Pharmacy HSA-compatible PPO

(combined medical and pharmacy OOPM)

Chiropractic / Acupuncture

Note: All flyers are customizable. To save the PDF with your benefit information included:

  • Select File > Print
  • In drop down mention next to "Printer", select "Adobe PDF"
  • Save in documents

Dental – HMO

Dental – PPO

Vision Plans

Full Network HMO

ExcelCare HMO

SmartCare HMO

Salud HMO y Más

Salud HMO y Más – Facility Deductible

Salud Mexico

CanopyCare HMO

CanopyCare HMO - Facility Deductible

Full Network EOA

Full Network EOA - Facility Deductible

ExcelCare EOA

ExcelCare EOA - Facility Deductible

PPO

PPO (HSA-compatible) (Includes pre-set pharmacy plans)

Pharmacy HMO

(combined medical and pharmacy OOPM)

Pharmacy POS – Elect Open Access (EOA)/ExcelCare EOA

Pharmacy HMO – Salud HMO y Más

(combined medical and pharmacy OOPM)

CanopyCare HMO

Pharmacy PPO

(combined medical and pharmacy OOPM)

Pharmacy HSA-compatible PPO

(combined medical and pharmacy OOPM)

Chiropractic / Acupuncture

Note: All flyers are customizable. To save the PDF with your benefit information included:

  • Select File > Print
  • In drop down mention next to "Printer", select "Adobe PDF"
  • Save in documents

Dental – HMO

Dental – PPO

Vision Plans

Covered California Collateral

Visit Covered California's printable materials such as fact sheets and collateral on their website.

Last Updated: 05/30/2024