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| AGC Health Benefit Trust - Oregon Columbia Chapter
January 2018 - December 2018 | |
| Link to Online Administration (SIMON) |
| LINK TO 2017 FORMS & DOCUMENTS
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| AGC of Oregon Website | | |
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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 |
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| Late Submission Letter |
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| EFT Authorization Form |
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| BSI COBRA Administrative Agreement |
| | Affidavit of Domestic Partnership |
| | Statement of Termination of Domestic Partnership |
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Compliance Resources |
Dollar Bank |
Section 125/CDHP Administration |
| Information Reporting Memo to Employers | Overview | Ameriflex Reference Guide |
| Summary Plan Description | Policy | Ameriflex ePOP+ Portal Benefits |
| Privacy Notice to Members | Application
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HIPAA Special Enrollment Notice
| | CDHP Administration Forms available upon request to: |
| HIPAA Release Form | | flexspending@bsitpa.com |
| COBRA Intitial Notice Template (BSI Administers) |
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| COBRA Initial Notice Template (BSI Does Not Administer) |
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| 2017 Medicare Part D - Creditable Coverage Notice | | |
| 2017 Medicare Part D - Creditable Coverage Letter | | |
| 2017 Medicare Part D - Non Creditable Coverage Notice | | |
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| Regence - Medical/Rx |
| Links, Forms & Helpful Information | SBC's | Contract Booklets |
| 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 |
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| Spanish SBC's available upon request to: service@agchealthplansnw.com | |
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| Wellness Program | Employee Assistance Program (EAP) | |
| Wellness Flyer - Employers | Employer EAP Flyer
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| Wellness Flyer - Employees | Employee EAP Flyer | |
| Employee EAP FAQs | |
| Legal and Financial Assistance Overview | |
| Work-Life Website Overview | |
| BPA Health Website | |
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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 |
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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) |
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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
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| Voluntary Accident Summary | Voluntary Accident Certificate | |
| MedEx Travel Assistance Brochure | | |
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| Voluntary Life & Accident Enrollment Form | Life Claim Form | Health Advocate Flyer
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| Life Beneficiary Form | AD&D Claim Form | Health Advocate Website |
| Voluntary Accident Claim Form |
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