2020 Documents and Summaries
Alaska Chapter
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
- 2020 Medicare Part D – Creditable Coverage Notice