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Welcome to AGC Health Benefit Trust
Oregon Columbia Chapter
2021

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

Dollar Bank

  • Overview
  • Policy
  • Application

CDHP Administration Forms available upon request to: flexspending@vimly.com

Medical/RX – Regence

Links, Forms & Helpful Information

  • Regence Website
  • Medical Claim Form
  • RX Mail Order Instructions – Wallgreens
  • RX Mail Order Form – Wallgreens
  • RX Reimbursement Form – Regence
  • Pharmacy Preferred Drug List
  • Pharmacy Prior Authorization List
  • Speciality Select Pharmacy Program

Summaries

  • PPO $500 RX 1
  • PPO $500 RX 2
  • PPO $500 RX 3
  • PPO $1,000 RX 1
  • PPO $1,000 RX 2
  • PPO $1,000 RX 3
  • PPO $1,500 RX 1
  • PPO $1,500 RX 2
  • PPO $1,500 RX 3
  • PPO $2,000 RX 1
  • PPO $2,000 RX 2
  • PPO $2,000 RX 3
  • PPO $3,000 RX 1
  • PPO $3,000 RX 2
  • PPO $3,000 RX 3
  • HSA $2,500 RX 30%
  • HSA 4500
  • Value $500 RX 1
  • Value $500 RX 2
  • Value $500 RX 3
  • Value $1,000 RX 1
  • Value $1,000 RX 2
  • Value $1,000 RX 3
  • Value $2,500 RX 1
  • Value $2,500 RX 2
  • Value $2,500 RX 3
  • Value $3,500 RX 1
  • Value $3,500 RX 2
  • Value $3,500 RX 3
  • Value $5,000 RX 1
  • Value $5,000 RX 2
  • Value $5,000 RX 3
  • Value $6,000 RX 1
  • Value $6,000 RX 2
  • Value $6,000 RX 3

SBC’s

  • PPO $500 RX 1
  • PPO $500 RX 2
  • PPO $500 RX 3
  • PPO $1,000 RX 1
  • PPO $1,000 RX 2
  • PPO $1,000 RX 3
  • PPO $1,500 RX 1
  • PPO $1,500 RX 2
  • PPO $1,500 RX 3
  • PPO $2,000 RX 1
  • PPO $2,000 RX 2
  • PPO $2,000 RX 3
  • PPO $3,000 RX 1
  • PPO $3,000 RX 2
  • PPO $3,000 RX 3
  • HSA $2,500 RX 30%
  • HSA 4500
  • Value $500 RX 1
  • Value $500 RX 2
  • Value $500 RX 3
  • Value $1,000 RX 1
  • Value $1,000 RX 2
  • Value $1,000 RX 3
  • Value $2,500 RX 1
  • Value $2,500 RX 2
  • Value $2,500 RX 3
  • Value $3,500 RX 1
  • Value $3,500 RX 2
  • Value $3,500 RX 3
  • Value $5,000 RX 1
  • Value $5,000 RX 2
  • Value $5,000 RX 3
  • Value $6,000 RX 1
  • Value $6,000 RX 2
  • Value $6,000 RX 3

Spanish SBC’s available upon request to: service@agchealthplansnw.com. 

Contract Booklets

  • PPO $500 RX 1
  • PPO $500 RX 2
  • PPO $500 RX 3
  • PPO $1,000 RX 1
  • PPO $1,000 RX 2
  • PPO $1,000 RX 3
  • PPO $1,500 RX 1
  • PPO $1,500 RX 2
  • PPO $1,500 RX 3
  • PPO $2,000 RX 1
  • PPO $2,000 RX 2
  • PPO $2,000 RX 3
  • PPO $3,000 RX 1
  • PPO $3,000 RX 2
  • PPO $3,000 RX 3
  • HSA $2,500 RX 30%
  • HSA 4500
  • Value $500 RX 1
  • Value $500 RX 2
  • Value $500 RX 3
  • Value $1,000 RX 1
  • Value $1,000 RX 2
  • Value $1,000 RX 3
  • Value $2,500 RX 1
  • Value $2,500 RX 2
  • Value $2,500 RX 3
  • Value $3,500 RX 1
  • Value $3,500 RX 2
  • Value $3,500 RX 3
  • Value $5,000 RX 1
  • Value $5,000 RX 2
  • Value $5,000 RX 3
  • Value $6,000 RX 1
  • Value $6,000 RX 2
  • Value $6,000 RX 3

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

  • $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

Vision – Standard

Links, Forms & Helpful Information

Benefit Summaries

  • Plan 100
  • Plan 150
  • Plan 100V (Voluntary)
  • Plan 150V (Voluntary)

Certificates

  • Plan 100
  • Plan 150
  • Plan 100V (Voluntary)
  • Plan 150V (Voluntary)

Wellness Program and Employee Assistance Program

Wellness Program

  • Wellness Flyer – Employers
  • Wellness Flyer – Employees

Employee Assistance Program (EAP)

  • Employer EAP Flyer
  • Employee EAP Flyer
  • Employee EAP FAQs
  • Legal and Financial Assistance Overview
  • Work-Life Website Overview
  • EAP Website (BPA Health)

Ancillary Benefits & Programs

Benefit & Program Summaries

  • Life/AD&D Benefit Summaries:
    • $10k
    • $20k
    • $25k
    • $30k
    • $50k
  • Voluntary Life Summary
  • Voluntary Accident Summary
  • MedEx Travel Assistance Brochure

Certificates

  • Life/AD&D Certificate (All Increments of Coverage)
  • 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
  • HIPAA Special Enrollment Notice
  • HIPAA Release Form
  • COBRA Initial Notice Template (Vimly Administration)
  • 2020 Medicare Part D – Creditable Coverage Notice
  • 2020 Medicare Part D – Non-Creditable Coverage Notice