AGC Health Benefit Trust - Oregon Columbia Chapter January 2017 - December 2017
Link to Online Administration (SIMON)		LINK TO 2016 FORMS & DOCUMENTS
AGC of Oregon Website
Program Overview	Quoting Materials	Submission Materials
Overview	Quote Request Form	Submission Checklist
Product Grid	Census Template	Employer Application
Underwriting Guidelines	Certificate of Revenue from Construction	Employee Enrollment Form
Member Contact Information		Employee Enrollment Form (Spanish)
BSI Administrative Guide		Enrollment Census Template
		SBC Acknowledgement Form
		Late Submission Letter
		EFT Authorization Form
		BSI COBRA Administrative Agreement
		Affidavit of Domestic Partnership
		Statement of Termination of Domestic Partnership
Compliance Resources	Dollar Bank	Section 125/CDHP Administration
Information Reporting Memo to Employers	Overview	Section 125 Adoption Agreement
Summary Plan Description	Policy	Section 125 Non-Discrimination Testing
Privacy Notice to Members	Application
HIPAA Special Enrollment Notice		CDHP Administration Forms available upon request to:
HIPAA Release Form		flexspending@bsitpa.com
COBRA Intitial Notice Template (BSI Administers)
COBRA Initial Notice Template (BSI Does Not Administer)
2017 Medicare Part D - Creditable Coverage Notice
2017 Medicare Part D - Creditable Coverage Letter
2017 Medicare Part D - Non Creditable Coverage Notice
Regence - Medical/Rx
Links, Forms & Helpful Information	SBC's	Certificates of Coverage
Regence Website	PPO $500 RX 1	PPO $500 RX 1
Medical Claim Form	PPO $500 RX 2	PPO $500 RX 2
RX Mail Order Instruction - Walgreens	PPO $1000 RX 1	PPO $1000 RX 1
RX Mail Order Form - Walgreens	PPO $1000 RX 2	PPO $1000 RX 2
RX Reimbursement Form - Regence	PPO $1500 RX 1	PPO $1500 RX 1
Pharmacy Preferred Drug List	PPO $1500 RX 2	PPO $1500 RX 2
Pharmacy Prior Authorization List	PPO $2000 RX 1	PPO $2000 RX 1
Specialty Select Pharmacy Program	PPO $2000 RX 2	PPO $2000 RX 2
	PPO $3000 RX 1	PPO $3000 RX 1
	PPO $3000 RX 2	PPO $3000 RX 2
	PPO $5000 RX 1	PPO $5000 RX 1
	PPO $5000 RX 2	PPO $5000 RX 2
	HSA $2500 RX 30%	HSA $2500 RX 30%
	HSA $6550	HSA $6550
	Value $1000 RX 1	Value $1000 RX 1
	Value $1000 RX 2	Value $1000 RX 2
	Value $2500 RX 1	Value $2500 RX 1
	Value $2500 RX 2	Value $2500 RX 2
	Value $5000 RX 1	Value $5000 RX 1
	Value $5000 RX 2	Value $5000 RX 2
	Spanish SBC's available upon request to: service@agchealthplansnw.com
Wellness Program	Employee Assistance Program (EAP)
Wellness Flyer - Employers	Employer EAP Flyer
Wellness Flyer - Employees	Employee EAP Flyer
	Employee EAP FAQs
	Legal and Financial Assistance Overview
	Work-Life Website Overview
	BPA Health Website
Standard Dental
Links, Forms & Helpful Information	Benefit Summaries	Certificates
Standard Website	$1,000 Annual Max	$1,000 Annual Max
Dental Claim Form	$1,500 Annual Max	$1,500 Annual Max
	$2,000 Annual Max	$2,000 Annual Max
	$1,000 Annual Max with Orthodontia	$1,000 Annual Max with Orthodontia
	$1,500 Annual Max with Orthodontia	$1,500 Annual Max with Orthodontia
	$2,000 Annual Max with Orthodontia	$2,000 Annual Max with Orthodontia
Standard (VSP) Vision
Links, Forms & Helpful Information	Benefit Summaries	Certificates
VSP Website	Plan 100	Plan 100
VSP Provider Lookup	Plan 150	Plan 150
VSP Out of Network Claim Form	Plan 100V (Voluntary)	Plan 100V (Voluntary)
	Plan 150V (Voluntary)	Plan 150V (Voluntary)
Ancillary Benefits & Programs
Life/AD&D Benefit Summaries: $10K, $20K, $25K, $30K, $50K	Life/AD&D Certificate (All Increments of Coverage)	LifeBalance Flyer
Voluntary Life Summary	Voluntary Life Certificate	LifeBalance Website
Voluntary Accident Summary	Voluntary Accident Certificate
MedEx Travel Assistance Brochure
Voluntary Life & Accident Enrollment Form	Life Claim Form
Life Beneficiary Form	AD&D Claim Form
	Voluntary Accident Claim Form