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
- Quote Request Form
- Census Template
- Certificate of Revenue from Construction
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
- Ameriflex ePOP+
- Ameriflex Premium Only Plan
- 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 750
- Preferred 1250
- Preferred 1500
- Preferred 2000
- Preferred 3000
- Consumer 1000
- Consumer 2000
- HSA 1750
- HSA 2500
- HSA 3000
Benefit Summaries
- Premier 500 RX $8/$25/$60/$250
- Premier 700 RX $8/$25/$60/$250
- Premier 750 ?
- Premier 1500 RX $15/$35/$65/$250
- Premier 2500 RX $15/$35/$65/$250
- Premier 3000 RX $15/$35/$65/$250
- Preferred 750 RX $15/$35/$65/$250
- Preferred 1250 RX $15/$35/$65/$250
- Preferred 1500 RX $15/$35/$65/$250
- Preferred 2000 RX $15/$35/$65/$250
- Preferred 3000 RX $15/$35/$65/$250
- Preferred 4000 ?
- Preferred 5000 ?
- Consumer 1000 RX $15/$35/$65/$250
- Consumer 2000 RX $15/$35/$65/$250
- HSA 1750 RX $15/$35/$65/$250
- HSA 2500 RX $15/$35/$65/$250
- HSA 3000 RX $15/$35/$65/$250
- HSA RX Only
- RX
SBC’s
- Premier 500 RX $8/$25/$60/$250
- Premier 700 RX $8/$25/$60/$250
- Premier 750 ?
- Premier 1500 RX $15/$35/$65/$250
- Premier 2500 RX $15/$35/$65/$250
- Premier 3000 RX $15/$35/$65/$250
- Preferred 750 RX $15/$35/$65/$250
- Preferred 1250 RX $15/$35/$65/$250
- Preferred 1500 RX $15/$35/$65/$250
- Preferred 2000 RX $15/$35/$65/$250
- Preferred 3000 RX $15/$35/$65/$250
- Preferred 4000 ?
- Preferred 5000 ?
- Consumer 1000 RX $15/$35/$65/$250
- Consumer 2000 RX $15/$35/$65/$250
- HSA 1750 RX $15/$35/$65/$250
- HSA 2500 RX $15/$35/$65/$250
- HSA 3000 RX $15/$35/$65/$250
Dental – Standard
Links, Forms & Helpful Information
- Standard Website
- Dental Claim Form
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
- VSP Choice $10/$25
- VSP Choice $10/$0
- Eye Med $10/$25
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)
- Life Beneficiary Form
- How to File a Life Claim
- Life Claim Form
- AD&D Claim Form
- Accelerated Death Benefits Claim Form
- Life Balance Flyer
- Health Advocate
- Top Reasons to Call
Certificates
- Voluntary Life Certificate
- Voluntary Accident Certificate
Forms
- Voluntary Life & Accident Enrollment Form
- Life Beneficiary Form
- Life Claim Form
- AD&D Claim Form
- Voluntary Accident Claim Form
Flyers & Resources
- LifeBalance Flyer
- LifeBalance Website
- Health Advocate Flyer
- Health Advocate Website
Compliance Resources
Resources
- Summary Plan Description
- Privacy Notice to Members
- COBRA Initial Notice Template (BSI Administers)
- COBRA Initial Notice Template (BSI Does Not Administer)
- HIPAA Release Form
- 2019 Medicare Part D – Creditable Coverage Notice