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Welcome to AGC Health Benefit Trust
Oregon Columbia Chapter

Program Overview
Overview
Product Grid
Underwriting Guidelines
Member Contact Information
Vimly Administration Guide

Customer Service 
Autumn Schwerdfager – Program 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 – United Healthcare

Links, Forms & Helpful Information

  • UHC Website
  • Welcome to myUHC Website
  • United Healthcare App
  • EAP
  • UHC Medical Claim Form
  • OptumRX Mail-in-Order Form
  • OptumRX Reimbursement Form

Summaries

  • Premier $500
  • Premier $1,000
  • Premier $1,500
  • Premier $2,000
  • Premier $3,000
  • Preferred $500
  • Preferred $1,000
  • Preferred $2,500
  • Preferred $3,500
  • Preferred $5,000
  • Preferred $6,000
  • HSA $2,500 w/Motion
  • HSA $4,500 w/ Motion
  • Advanced $500
  • Advanced $1,000
  • Advanced $2,000
  • Advanced $3,000
  • Advanced $5,000
  • RX1
  • RX2
  • RX3
  • RX4
  • RX5 (HSA)
  • RX6 (HSA)

SBC’s

  • Premier $500 RX 1
  • Premier $500 RX 2
  • Premier $500 RX 3
  • Premier $500 RX 4
  • Premier $1,000 RX 1
  • Premier $1,000 RX 2
  • Premier $1,000 RX 3
  • Premier $1,000 RX4
  • Premier $1,500 RX1
  • Premier $1,500 RX2
  • Premier $1,500 RX3
  • Premier $1,500 RX4
  • Premier $2,000 RX1
  • Premier $2,000 RX2
  • Premier $2,000 RX3
  • Premier $2,000 RX4
  • Premier $3,000 RX1
  • Premier $3,000 RX2
  • Premier $3,000 RX3
  • Premier $3,000 RX4
  • Preferred $500 RX1
  • Preferred $500 RX2
  • Preferred $500 RX3
  • Preferred $500 RX4
  • Preferred $1,000 RX1
  • Preferred $1,000 RX2
  • Preferred $1,000 RX3
  • Preferred $1,000 RX4
  • Preferred $2,500 RX1
  • Preferred $2,500 RX2
  • Preferred $2,500 RX3
  • Preferred $2,500 RX4
  • Preferred $3,500 RX1
  • Preferred $3,500 RX2
  • Preferred $3,500 RX3
  • Preferred $3,500 RX4

 

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

SBC’s

  • Preferred $5,000 RX1
  • Preferred $5,000 RX2
  • Preferred $5,000 RX3
  • Preferred $5,000 RX4
  • Preferred $6,000 RX1
  • Preferred $6,000 RX2
  • Preferred $6,000 RX3
  • Preferred $6,000 RX4
  • HSA $2,500 w/Motion RX 5
  • HSA $2,500 w/Motion RX 6
  • HSA $4,500 w/Motion RX 5
  • HSA $4,500 w/Motion RX 6
  • Advanced $500 RX 1
  • Advanced $500 RX 2
  • Advanced $500 RX 3
  • Advanced $500 RX 4
  • Advanced $1,000 RX 1
  • Advanced $1,000 RX 2
  • Advanced $1,000 RX 3
  • Advanced $1,000 RX 4
  • Advanced $2,000 RX1
  • Advanced $2,000 RX2
  • Advanced $2,000 RX3
  • Advanced $2,000 RX4
  • Advanced $3,000 RX1
  • Advanced $3,000 RX2
  • Advanced $3,000 RX3
  • Advanced $3,000 RX4
  • Advanced $5,000 RX1
  • Advanced $5,000 RX2
  • Advanced $5,000 RX3
  • Advanced $5,000 RX4

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

Medical/RX – United Healthcare

Links, Forms & Helpful Information

  • UHC Website
  • Welcome to myUHC Website
  • United Healthcare App
  • EAP
  • UHC Medical Claim Form
  • OptumRX Mail-in-Order Form
  • OptumRX Reimbursement Form

Vision – Standard

Links, Forms & Helpful Information

Benefit Summaries

Certificates

Ancillary Benefits & Programs

Benefit & Program Summaries

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

Certificates

  • Life/AD&D Certificate (All Increments of Coverage)

Forms

  • Life Beneficiary Form
  • Life Claim Form
  • AD&D Claim Form

Flyers & Resources

  • LifeBalance Flyer
  • LifeBalance Website

Compliance Resources

Resources

  • Summary Plan Description
  • Privacy Notice to Members
  • HIPAA Special Enrollment Notice
  • HIPAA Release Form
  • COBRA Initial Notice Template (Vimly Administration)
  • Med D – Cover Letter
  • 2021 Medicare Part D – Creditable Coverage Notice