Group Administrator Links, Documents and Forms - 2012 Plan Year

 2011 Plan Year - Click Here

Account Log-in (BSI site for Billing and Eligibility Changes) Contact Customer Service
Carrier Forms Quick Links: Health Net, Lifewise Assurance, Guardian Dental, Superior Vision, LifeBalance,
Other Quick Links: COBRA & CDHP, Enrollment/Change/Waiver Forms, General Forms
Lifewise Assurance - Life and STD		Back to Top
Links	Benefit Summaries	Certificates/Booklets
Lifewise Assurance Website Administrative Forms Beneficiary Change Form AGC Group Life Claim Form STD Claim Form	$10,000 Life/AD&D Certificate (2-9 Employees) $20,000 Life/AD&D Certificate (2-9 Employees) $10,000 Life/AD&D Certificate (10+ Employees) $20,000 Life/AD&D Certificate (10+ Employees) $30,000 Life/AD&D Certificate (10+ Employees) $40,000 Life/AD&D Certificate (10+ Employees) $50,000 Life/AD&D Certificate (10+ Employees) STD $300 13 Weeks STD $500 13 Weeks STD $300 26 Weeks STD $500 26 Weeks	$10,000 Life/AD&D Plan Summary $20,000 Life/AD&D Plan Summary $30,000 Life/AD&D Plan Summary $40,000 Life/AD&D Plan Summary $50,000 Life/AD&D Plan Summary STD $300 13 Weeks STD $500 13 Weeks STD $300 26 Weeks STD $500 26 Week LifeWise Policy
Health Net - Medical, RX		Back to To
Links	Benefit Summaries PPO	SBC's
HealthNet Website Provider Search Pharmacy Search Administrative Forms HIPAA Authorization Forms State Continuation Election Form CVS Caremark Rx Mail Order Form CVS Caremark Rx Mail Order Instructions RX Reimbursement Form Miscellaneous Documents Member Handbook Decision Power Pharmacy Benefit Guide - Preferred Drug List Pharmacy Benefit Guide - Limited Quantity List Pharmacy Benefit Guide - Prior Authorization Req'd Healthy Discounts Prior Authorization Requirements OR Temporary ID Card Plan Contract PPO Plan Contract - 2012 PPO 2012 Summary of Contract Changes Prior Year Benefit Summaries 2011  Benefit Summaries 2010  Benefit Summaries	PPO $250 (A15-250-2-2500) PPO $500 (Only Available to those currently enrolled) PPO $750 (GSA-20-750-2-2500) PPO $1000  (A25-1000-2-3000) PPO $1500  (A30-1500-2-3000) PPO $2000 (GSA30-2000-2-4000) PPO $3000 (A30-3000-2-3000) PPO $5000 (A35-5000-2-3000) PPO $7500 (GSA35-7500-2-5000) Value $1000 (Only available to those currently enrolled) 50-50-2500 (Only available to those currently enrolled) 50-50-5000 (Only available to those currently enrolled) Benefit Summaries - Essentials Essential $1000 (GSE25-1000-3-5000) Essential $2000 (GSE30-2000-3-5000) Essential $3000 (GSE35-3000-3-5000) Essential $5000 (GSE35-5000-3-5000) Essential $7500 (GSE35-7500-3-5000) Benefit Summaries RX RX $10/$25/$50 RX $15/$30/$50 RX $10/$50/$75 Other Riders HN Well Net Benefit Buy-Up Options HN Well Net Buy-Up	PPO $250 SBC PPO $500 SBC PPO $750 SBC PPO $1000  SBC PPO $1500  SBC PPO $2000 SBC PPO $3000 SBC PPO $5000 SBC PPO $7500 SBC Value $1000 SBC 50-50-2500 SBC 50-50-5000 SBC Benefit Summaries - Essentials Essential $1000 SBC Essential $2000 SBC Essential $3000 SBC Essential $5000 SBC Essential $7500 SBC
Superior Vision		LifeBalance                                      Back to Top
Links	Benefit Summaries Group Plans (enrollment must follow medical enrollment)	Links
Superior Vision Website Getting Started with Superior Member Guide Provider Nomination Form Overview - Finding a Provider Provider Directory - web search S.V. HIPAA Notice (PDF) S.V. Privacy Notice (PDF)	Plan 100 Plan 150 Plan 100/150 Comparison Plan 100 Certificate Plan 150 Certificate Amendment to Age 26 Voluntary Plans (employee paid; no minimum enrollment required) Plan 100V Plan 150V Plan 100V/150V Comparison Plan 100V Certificate Plan 150V Certificate Amendment to Age 26	LifeBalance Website Provider Network LifeBalance Benefits LifeBalance Program Flyer
Guardian Dental
Links	Benefit Summaries	Certificate Booklets
Guardian Provider Search Guardian Dental Maximum Rollover Handout Maximum Rollover for  Guardian Plan 1000 Maximum Rollover for  Guardian Plan 1500 Maximum Rollover for  Guardian Plan 2000	Guardian Plan 1000 Guardian Plan 1000 w/ Ortho Guardian Plan 1500 Guardian Plan 1500 w/ Ortho Guardian Plan 2000 Guardian Plan 2000 w/ Ortho	Guardian Plan 1000  Booklet Guardian Plan 1000 w/ Ortho Booklet Guardian Plan 1500 Booklet Guardian Plan 1500 w/ Ortho Booklet Guardian Plan 2000  Booklet Guardian Plan 2000 w/ Ortho Booklet
COBRA & CDHP – Benefit Solutions, Inc.  (BSI)		Back to Top
COBRA BSI COBRA Administration Information BSI COBRA Administrative Agreement Initial Notice Template (Employer must distribute)	CDHP BSI Cafeteria Plan Adoption Agreement CDHP Group Enrollment Form CDHP Group Enrollment Form BSI CDHP Employee Enrollment Form - FSA BSI CDHP Employee Enrollment Form - HRA BSI CDHP Employee Enrollment Form - HSA	BSI FSA/HSA/HRA Administration Information BSI Reference Guide BSI CDHP Information CDHP Informational Flyers FSA/HSA/HRA Flyer with Pricing
General Forms		Back to Top
Enrollment/Change/Waiver Form Domestic Partner Affidavit Program Highlights State Continuation Election Form Medicare Secondary Payer / TEFRA Explanation	Billing & Premium Process BSI Reference Guide EFT Form, Terms & Conditions	SPD Documents 2012 Summary Plan Description (SPD) 2012 SPD Letter to Employers

Willis  - General Agent

(866) 873-6175

Fax: (866) 999-3485

service@agchealthplansnw.com