AGC Health Benefit Trust - Oregon Columbia Chapter
January 2016 - December 2016
Link to Online Administration (SIMON)
LINK TO 2015 FORMS & DOCUMENTS
AGC of Oregon Website

Program Overview

Quoting Materials

Submission Materials
OverviewQuote Request FormSubmission Checklist
Product GridCensus TemplateEmployer Application
Underwriting GuidelinesCertificate of Revenue from ConstructionEmployee Enrollment Form
Member Contact InformationEmployee Enrollment Form (Spanish)
BSI Administrative GuideEnrollment 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 EmployersOverviewSection 125 Adoption Agreement
Summary Plan DescriptionPolicySection 125 Non-Discrimination Testing
Privacy Notice to MembersApplication

HIPAA Special Enrollment Notice
CDHP Administration Forms available upon request to:
HIPAA Release Formflexspending@bsitpa.com
COBRA Intitial Notice Template (BSI Administers)

COBRA Initial Notice Template (BSI Does Not Administer)

2015 Medicare Part D Creditable Coverage Notice
Regence - Medical/Rx
Links, Forms & Helpful InformationSBC'sCertificates of Coverage
Regence WebsitePPO $500 RX $15/$30/$50/$200PPO $500 RX $15/$30/$50/$200
Medical Claim FormPPO $500 RX $10/$50/$75/$200PPO $500 RX $10/$50/$75/$200
RX Mail Order Instruction - Walgreens PPO $1000 RX $15/$30/$50/$200PPO $1000 RX $15/$30/$50/$200
RX Mail Order Form - WalgreensPPO $1000 RX $10/$50/$75/$200PPO $1000 RX $10/$50/$75/$200
RX Reimbursement Form - RegencePPO $1500 RX $15/$30/$50/$200PPO $1500 RX $15/$30/$50/$200
Pharmacy Preferred Drug ListPPO $1500 RX $10/$50/$75/$200PPO $1500 RX $10/$50/$75/$200
Pharmacy Prior Authorization ListPPO $2000 RX $15/$30/$50/$200PPO $2000 RX $15/$30/$50/$200
Specialty Select Pharmacy ProgramPPO $2000 RX $10/$50/$75/$200PPO $2000 RX $10/$50/$75/$200
PPO $3000 RX $15/$30/$50/$200PPO $3000 RX $15/$30/$50/$200

PPO $3000 RX $10/$50/$75/$200PPO $3000 RX $10/$50/$75/$200

PPO $5000 RX $15/$30/$50/$200PPO $5000 RX $15/$30/$50/$200
PPO $5000 RX $10/$50/$75/$200PPO $5000 RX $10/$50/$75/$200
HSA $2500 RX 30%HSA $2500 RX 30%
ACO $1200 RX $20/$40/$60/$200ACO $1200 RX $20/$40/$60/$200
ActiveCare Provider Network
Value $1000 RX $15/$30/$50/$200Value $1000 RX $15/$30/$50/$200
Value $1000 RX $10/$50/$75/$200Value $1000 RX $10/$50/$75/$200
Value $2500 RX $15/$30/$50/$200Value $2500 RX $15/$30/$50/$200
Value $2500 RX $10/$50/$75/$200Value $2500 RX $10/$50/$75/$200
Value $5000 RX $15/$30/$50/$200Value $5000 RX $15/$30/$50/$200
Value $5000 RX $10/$50/$75/$200Value $5000 RX $10/$50/$75/$200
HSA $6550 HSA $6550 
Spanish SBC's available upon request to: service@agchealthplansnw.com


Wellness ProgramEmployee Assistance Program (EAP)
Why Wellnesss? PresentationEmployer EAP Flyer
Wellness Flyer - EmployersEmployee EAP Flyer
Wellness Flyer - EmployeesEmployee EAP FAQs
Physician Fax Screening FormLegal and Financial Assistance Overview
Work-Life Website Overview
BPA Health Website
2016 Calendar of Webinars

Standard Dental
Links, Forms & Helpful InformationBenefit SummariesCertificates
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 InformationBenefit SummariesCertificates
VSP WebsitePlan 100Plan 100
VSP Provider LookupPlan 150Plan 150
VSP Out of Network Claim FormPlan 100V (Voluntary)Plan 100V (Voluntary)

Plan 150V (Voluntary)Plan 150V (Voluntary)

Ancillary Benefits & Programs
Life/AD&D Benefit Summaries: $10K, $20K, $25K, $30K, $50KLife/AD&D Certificate (All Increments of Coverage)LifeBalance Flyer
Voluntary Life SummaryVoluntary Life CertificateLifeBalance Website
Voluntary Accident SummaryVoluntary Accident Certificate
MedEx Travel Assistance Brochure



Voluntary Life & Accident Enrollment FormLife Claim FormCoPatient Flyer (for Brokers)
Life Beneficiary FormAD&D Claim FormCoPatient Flyer (for Employers)

Voluntary Accident Claim FormCoPatient Flyer (for Employees)
CoPatient Website