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Welcome to AGC Health Benefit Trust
Oregon Columbia Chapter
2021

SIMON ACOUNT LOGIN

AGC OF OREGON WEBSITE

PRIOR YEARS DOCUMENTS & SUMMARIES

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 & 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

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

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 (VSP)

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 & EAP

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

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

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