Welcome to AGC Health Benefit Trust
Oregon Columbia Chapter
2021 Part Two
(October 1st 2021-September 30th 2022)
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
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
CDHP Administration Forms available upon request to: flexspending@vimly.com
Medical/RX – United Healthcare
Links, Forms & Helpful Information
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
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
Spanish SBC’s available upon request to: service@agchealthplansnw.com.
SBC’s
- 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
- 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
Spanish SBC’s available upon request to: service@agchealthplansnw.com.
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