2019 Documents & Summaries
Washington Chapter
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 – United Healthcare
Links, Forms & Helpful Information
- UHC Website
- Welcome to myUHC Website
- Health4Me Flyer
- EAP/Care 24
- UHC Medical Claim Form
- Flu Shot Reimbursement Form
- OptumRx Mail-in Order Form
- OptumRx Reimbursement Form
- Navigate Overview
- Navigate FAQ’s
- Navigate-Choosing a Primary Care Physician
SBC’s
- Premier 250
- Premier 500
- Premier 1000
- Premier 1500
- Premier 2000
- Preferred 1000
- Preferred 2000
- Preferred 2500
- Preferred 3000
- Preferred 5000
- HSA 1500
- HSA 2000 Custom (with motion)
- HSA 3500
- HSA 5000 Custom (with motion)
- Primary Advantage 2000
- Charter 3500
- Navigate 500
- Navigate 1750
- Navigate 2500
- Navigate 3500
Benefit Summaries
- Premier 250
- Premier 500
- Premier 1000
- Premier 1500
- Premier 2000
- Preferred 1000
- Preferred 2000
- Preferred 2500
- Preferred 3000
- Preferred 5000
- HSA 1500
- HSA 2000 Custom (with motion)
- HSA 3500
- HSA 5000 Custom (with motion)
- Primary Advantage 2000
- Charter 3500
- Navigate 500
- Navigate 1750
- Navigate 2500
- Navigate 3500
- Rx Plan 451 -$15/$40/$70/$250
- Rx Plan 495 – $15/$45/$85/20%
Certificates of coverage available upon request to: service@agchealthplansnw.com
Dental – Delta Dental
Links, Forms & Helpful Information
- Delta Dental Website
- Delta Dental Provider Lookup
- Dental Claim Form
- My Smile Flyer
- Power Your Smile Brochure
Benefit Summaries
Vision – Standard
Links, Forms & Helpful Information
Benefit Summaries
Certificates
Ancillary Benefits & Programs
Benefit & Program Summaries
- United Healthcare Life/AD&D Benefit Summaries:
- Life/AD&D Certificate (All Increments of Coverage)
- Life Beneficiary Form
- How to File a Life Claim
- Life Claim Form
- AD&D Claim Form
- Accelerated Death Benefits Claim Form
- LifeBalance Flyer