Program Overview
Overview
Product Grid
Underwriting Guidelines
Member Contact Information
Vimly Administration Guide
Prior year summaries, forms, etc. available on request.
Customer Service
Autumn Schwerdfager – Senior Account Manager
cell: 503.462.4041
direct: 503.977.5704
fax: 360.735.3144
toll-free: 800.735.8325
e: service@agchealthplansnw.com
Quoting & Submission Materials
Quoting Materials
Submission Materials
- Submission Checklist
- Employer Application
- Employee Enrollment Form
- Enrollment Census Template
- SBC Acknowledgement Form
- Late Submission Letter
- EFT Authorization Form
- Vimly COBRA Administrative Agreement
CDHP Administration
- CDHP Overview
- CDHP Administration Forms available upon request to: flexspending@vimly.com
Dollar Bank
Medical/RX – United Healthcare
Certificates
- Premier 500
- Premier 750
- Premier 1500
- Premier 2500
- Premier 3000
- Preferred 1500
- Preferred 2000
- Preferred 3000
- Preferred 4000
- Preferred 5000
- Consumer 1000
- Consumer 2000
- HSA 1750
- HSA 2500
- HSA 3000
Benefit Summaries
- Premier 500 RX $8/$35/$75/50%
- Premier 750 RX $8/$35/$75/50%
- Premier 1500 RX $15/$50/$150/50%
- Premier 2500 RX $15/$50/$150/50%
- Premier 3000 RX $15/$50/$150/50%
- Preferred 1500 RX $15/$50/$150/50%
- Preferred 2000 RX $15/$50/$150/50%
- Preferred 3000 RX $15/$50/$150/50%
- Preferred 4000 RX $15/$50/$150/50%
- Preferred 5000 RX $15/$50/$150/50%
- Consumer 1000 RX $15/$50/$150/50%
- Consumer 2000 RX $15/$50/$150/50%
- HSA 1750 RX $15/$50/$150/50%
- HSA 2500 RX $15/$50/$150/50%
- HSA 3000 RX $15/$50/$150/50%
- HSA RX Only
- RX
SBC’s
- Premier 500 RX $8/$35/$75/50%
- Premier 750 RX $8/$35/$75/50%
- Premier 1500 RX $15/$50/$150/50%
- Premier 2500 RX $15/$50/$150/50%
- Premier 3000 RX $15/$50/$150/50%
- Preferred 1500 RX $15/$50/$150/50%
- Preferred 2000 RX $15/$50/$150/50%
- Preferred 3000 RX $15/$50/$150/50%
- Preferred 4000 RX $15/$50/$150/50%
- Preferred 5000 RX $15/$50/$150/50%
- Consumer 1000 RX $15/$50/$150/50%
- Consumer 2000 RX $15/$50/$150/50%
- HSA 1750 RX $15/$50/$150/50%
- HSA 2500 RX $15/$50/$150/50%
- HSA 3000 RX $15/$50/$150/50%
Dental – Standard
Links, Forms & Helpful Information
Benefit Summaries
- $1,000 Annual Max
- $1,500 Annual Max
- $2,000 Annual Max
- $1,000 Annual Max with Orthodontia
- $1,500 Annual Max with Orthodontia
- $2,000 Annual Max with Orthodontia
Certificates
Vision – Standard
Links, Forms & Helpful Information
- VSP Website
- VSP Provider Lookup
- VSP Out of Network Claim Form
- Eye Med Out of Network Claim Form
- Choice Balance Care – Generic Eye Care Claim Reimbursement Form
Benefit Summaries
Certificates
Ancillary Benefits & Programs
Benefit & Program Summaries
- United Healthcare Life/AD&D Benefit Overview
- Life/AD&D Benefit Summaries:
- Life/AD&D Certificate (All Increments of Coverage)
- How to File a Life Claim
Forms
Flyers & Resources
Compliance Resources
Resources
- Summary Plan Description
- Privacy Notice to Members
- COBRA Initial Notice Template (Vimly Administers)
- COBRA Initial Notice Template (Vimly Does Not Administer)
- HIPAA Release Form
- 2019 Medicare Part D – Creditable Coverage Notice – Coming Soon