Documents & Forms
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The forms and materials available on this page are not specific to any particular plan. If you have questions about your plan's coverage, please check your benefit materials, or contact our Customer Service Department.
2022 ID Large Group Master Application (Medical/Dental)
2022 ID Small Group Master Application (Medical/Dental)
2022 MT Large Group Master Application (Medical/Dental)
2022 MT Small Group Master Application (Medical/Dental)
2022 OR Large Group Master Application (Medical/Dental)
2022 OR Small Group Master Application (Medical/Dental)
2022 WA Large Group Master Application (Medical/Dental)
2022 WA Small Group Master Application (Medical/Dental)
2023 ID Large Group Master Application (Medical/Dental)
2023 ID Small Group Master Application (Medical/Dental)
2023 MT Large Group Master Application (Medical/Dental)
2023 MT Small Group Master Application (Medical/Dental)
2023 OR Large Group Master Application (Medical/Dental)
2023 OR Small Group Master Application (Medical/Dental)
2023 WA Large Group Master Application (Medical/Dental)
2023 WA Small Group Master Application (Medical/Dental)
Accident Report (Medical Service Questionnaire)
Advantage Dental Network Nomination
Attestation of Eligibility
Behavioral Health: Admission Notification Form
Behavioral Health: Preauthorization Request Form for ABA Services
CHE Budget Form
Claim Form - Dental
Claim Form - Medical
Claim Status Request
COBRA Election Form Federal Template
COBRA Initial Notice Template
Common Ownership Form
Contact Information Request Form
Coordination of Benefits
Corrected Dental Claim Form
Corrected Medical Claim Form
Credentialing - Add a Hospital Based Provider - Provider Information Request Form - ID MT
Credentialing - Add a Hospital-based Provider - OR WA
Credentialing - Interest Packet for Facilities and Hospitals - OR
Credentialing - Interest Packet for Providers - OR
Credentialing - Recredentialing Application for Providers - OR
Credentialing Application for Facilities and Hospitals - ID MT
Credentialing Application for Facilities and Hospitals - OR WA
Credentialing Application for Providers - ID MT
Credentialing Application for Providers - OR with criteria checklist
Credentialing Application for Providers - WA
Dental Claims Referral Form - Dental Essentials
Designation of Authorized Representative
Electronic Remittance Advice (835) and EFT Authorization Agreement
Employer Exemption Certification for Religious or Moral Objections - WA
First Health Network Nomination
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT)
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT) - Self-funded
Group Coverage Continuation Election Form (WA small group)
Group Identification Form - MT, OR, WA
Individual Policy Change Form
Large Group Census - ID (CURV)
Large Group Census - MT
Large Group Request for Quote (census form) - WA
Member Appeal Form
Oregon Request for Confidential Communication
Parent/Guardian Information Form
Prescription Drug Claim Form
Prior Authorization Checklist - Blepharoplasty
Prior Authorization Checklist - Bone Growth (Electronic and Ultrasonic) Stimulators
Prior Authorization Checklist - Dental as Medical
Prior Authorization Checklist - Instrumented Spinal Surgery
Prior Authorization Checklist - Reduction Mammoplasty
Prior Authorization Request Form
Prior Authorization/Medication Exception Request Form
Proposal Request: Fully Insured (Large Group 51-99) - WA
Proposal Request: Fully-Insured (Large Group 51-99) - ID
Prospective Agent Appointment Form
Provider Appeal Form
Provider Information Request - ID and MT
Provider Information Request - OR and WA
Provider Nomination Form
Provider Offshore Operations Attestation
Quote Request for Small Groups
Renewal Confirmation Form
Request a copy of my health information
Request Accounting of Disclosures
Request for Quote Large Group (51+) - MT
Request to correct or add to my health records
Request to restrict access to my health information
Short Form Health Statement (required if no claims experience submitted) - MT
Split Carrier Waiver of Coverage
Universal Application (Mid-size Group 51-99) - ID
ACA Reporting Requirements Guide
CHE Application Guide
CHE Collaborations 2019-2020
Continuation of Coverage Laws FAQ for Members (Oregon only)
COVID-19 Benefit and Reimbursement Policy FAQ
COVID-19 Provider Relief Plan FAQ
Credentialing Application Rights
Credentialing Criteria
Diagnostic Imaging Prior Authorization List
Drug List - Prior Authorization Criteria
Drug List - Step Therapy Criteria
EFT Payment FAQ
InTouch for Providers Resource Guide
New and Emerging Technologies: Coverage Status
PacificSource Foundation 2021 Impact Report
Pharmacy Network for ID, MT, OR, and WA
Pharmacy Network for ID, MT, OR, and WA (Excel format)
Provider Network Contact List
Provider Peer to Peer FAQ
Recredentialing Criteria
Winning at Wellness Workbook
2022 ID Individual and Family Brochure - Navigator
2022 ID Individual and Family Brochure - Voyager
2022 ID Individual and Family Dental Only Plan Comparison
2022 ID Individual and Family Medical Plan Comparison - Navigator
2022 ID Individual and Family Medical Plan Comparison - Voyager
2022 ID Individual and Family Plan Rates (Navigator)
2022 ID Individual and Family Plan Rates (Voyager)
2022 ID Large Group Brochure - Dental Only
2022 ID Large Group Brochure - Navigator
2022 ID Large Group Brochure - Voyager
2022 ID Sample General Medical Limitations and Exclusions
2022 ID Small Group Brochure - Navigator
2022 ID Small Group Brochure - Voyager
2022 ID Small Group Dental Only Plan Comparison
2022 ID Small Group Medical Plan Comparison - Navigator
2022 ID Small Group Medical Plan Comparison - Voyager
2022 Idaho Individual Dental Exclusions
2022 Idaho Small Group Dental Exclusions
2022 MT Individual and Family Brochure - Navigator
2022 MT Individual and Family Dental Only Plan Comparison
2022 MT Individual and Family Medical Plan Comparison - Navigator
2022 MT Individual and Family Plan Rates
2022 MT Large Group Brochure
2022 MT Large Group Brochure - Dental Only
2022 MT Small Group Brochure - Navigator
2022 MT Small Group Dental Only Plan Comparison
2022 MT Small Group Medical Plan Comparison - Navigator
2022 OR Individual and Family Brochure - Navigator
2022 OR Individual and Family Dental Only Plan Comparison
2022 OR Individual and Family Errata for Medical Plan Comparison and Brochure
2022 OR Individual and Family Medical Plan Comparison - Navigator
2022 OR Individual and Family Plan Rates
2022 OR Large Group Brochure - Dental Only
2022 OR Large Group Brochure - Navigator
2022 OR Large Group Brochure - Voyager
2022 OR Small Group Brochure - Navigator
2022 OR Small Group Brochure - Voyager
2022 OR Small Group Dental Only Plan Comparison
2022 OR Small Group Medical Plan Comparison - Navigator
2022 OR Small Group Medical Plan Comparison - Voyager
2022 WA Health Plan Disclosure
2022 WA Individual and Family Plan Rates
2022 WA Large Group Brochure - Navigator
2022 WA Large Group Brochure - Voyager
2022 WA Large Group Dental Only Brochure
2022 WA Small Group Brochure - Navigator
2022 WA Small Group Brochure - Voyager
2022 WA Small Group Dental Only Plan Comparison
2022 WA Small Group Medical Plan Comparison - Navigator
2022 WA Small Group Medical Plan Comparison - Voyager
2023 ID Individual and Family Brochure - Navigator
2023 ID Individual and Family Brochure - Voyager
2023 ID Individual and Family Dental Only Plan Comparison
2023 ID Individual and Family Medical Plan Comparison - Navigator
2023 ID Individual and Family Medical Plan Comparison - Voyager
2023 ID Individual and Family Plan Rates (Navigator)
2023 ID Individual and Family Plan Rates (Voyager)
2023 ID Large Group Brochure - Dental Only
2023 ID Large Group Brochure - Navigator
2023 ID Large Group Brochure - Voyager
2023 ID Sample General Medical Limitations and Exclusions
2023 ID Small Group Brochure - Navigator
2023 ID Small Group Brochure - Voyager
2023 ID Small Group Dental Only Plan Comparison
2023 ID Small Group Medical Plan Comparison - Navigator
2023 ID Small Group Medical Plan Comparison - Voyager
2023 Idaho Individual Dental Exclusions
2023 Idaho Small Group Dental Exclusions
2023 MT Individual and Family Brochure - Navigator
2023 MT Individual and Family Dental Only Plan Comparison
2023 MT Individual and Family Medical Plan Comparison - Navigator
2023 MT Individual and Family Plan Rates
2023 MT Large Group Brochure - Dental Only
2023 MT Large Group Brochure - Navigator
2023 MT Small Group Brochure - Navigator
2023 MT Small Group Dental Only Plan Comparison
2023 MT Small Group Medical Plan Comparison - Navigator
2023 OR Individual and Family Brochure - Navigator
2023 OR Individual and Family Dental Only Plan Comparison
2023 OR Individual and Family Medical Plan Comparison - Navigator
2023 OR Individual and Family Plan Rates
2023 OR Large Group Brochure - Dental Only
2023 OR Large Group Brochure - Navigator
2023 OR Large Group Brochure - Voyager
2023 OR Small Group Brochure - Navigator
2023 OR Small Group Brochure - Voyager
2023 OR Small Group Dental Only Plan Comparison
2023 OR Small Group Medical Plan Comparison - Navigator
2023 OR Small Group Medical Plan Comparison - Voyager
2023 WA Health Plan Disclosure
2023 WA Individual and Family Plan Rates
2023 WA Large Group Brochure - Navigator
2023 WA Large Group Brochure - Voyager
2023 WA Large Group Dental Only Brochure
2023 WA Small Group Brochure - Navigator
2023 WA Small Group Brochure - Voyager
2023 WA Small Group Dental Only Plan Comparison
2023 WA Small Group Medical Plan Comparison - Navigator
2023 WA Small Group Medical Plan Comparison - Voyager
Balance Billing Protection Notice for ID
Balance Billing Protection Notice for MT
Balance Billing Protection Notice for OR
Balance Billing Protection Notice for WA
Drug List - Prior Authorization Criteria
Drug List - Step Therapy Criteria
Employer Administration Manual
Expanded No-cost Drug List
Large Group ID Self-Funded Dental Flier
Large Group MT Self-Funded Dental Flier
Large Group OR Self-Funded Dental Flier
Large Group WA Self-Funded Dental Flier
Medicare Notice A (creditable) Sample Member Notice
Medicare Notice B (noncreditable) Sample Member Notice
Medicare Part D Creditable Coverage FAQ
Medicare Part D Employer Creditability Notice
Medicare Part D ID 2022 Creditability Matrix
Medicare Part D ID 2023 Creditability Matrix
Medicare Part D MT 2022 Creditability Matrix
Medicare Part D MT 2023 Creditability Matrix
Medicare Part D OR 2022 Creditability Matrix
Medicare Part D OR 2023 Creditability Matrix
Medicare Part D WA 2022 Creditability Matrix
Medicare Part D WA 2023 Creditability Matrix
Member Guide (for members with dental-only plans)
Pharmacy Product Guidelines FAQ
Self-Funded Administrative Solutions
Value Based Preventive Drug List