AGC Health Benefit Trust
Oregon Columbia Chapter
2021 Part One (January-September)
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
Dollar Bank
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
- RX Mail Order Instructions – Express
- RX Mail Order Form – Express
- 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
Vision – Standard
Links, Forms & Helpful Information
Benefit Summaries
Certificates
Wellness Program and Employee Assistance Program
Wellness Program
Employee Assistance Program (EAP)
Ancillary Benefits & Programs
Benefit & Program Summaries
- Life/AD&D Benefit Summaries:
- Voluntary Life Summary
- Voluntary Accident Summary
- Travel Assistance Brochure
Certificates
- Life/AD&D Certificate (All Increments of Coverage)
- Voluntary Life Certificate
- Voluntary Accident Certificate