AGC Health Benefit Trust - Alaska Washington Chapters

AGC Health Benefit Trust - Alaska Chapter
June 2019 - May 2020

Link to Online Administration (SIMON)
AGC of Alaska Website

Program Overview

Quoting Materials

Submission Materials
OverviewQuote Request FormSubmission Checklist
Product GridCensus TemplateEmployer Application
Underwriting Guidelines
Employee Enrollment Form
Member Contact Information
Enrollment Census Template
Vimly Administrative Guide
SBC Acknowledgement Form

Late Submission Letter

EFT Authorization Form

Vimly COBRA Administrative Agreement

Compliance Resources

Dollar Bank

Section 125/CDHP Administration
Summary Plan Description
OverviewAmeriflex Reference Guide 
Privacy Notice to MembersPolicyAmeriflex ePOP+ Portal Benefits 
COBRA Initial Notice Template (BSI Administers)Application

COBRA Initial Notice Template (BSI Does Not Administer)

HIPAA Release Form
CDHP Administration Forms available upon request to:
2019 Medicare Part D - Creditable Coverage Letter

CDHP Overview

United Healthcare - Medical/Rx
Links, Forms & Helpful Information

UHC WebsiteUHC Medical Claim FormHealth4Me App
Welcome to myUHCFlu Shot Reimbursement FormEAP/Care 24 Member Flyer
UHC Healthcare Cost Estimator
Virtual Visits (Telemedicine Benefits)

Benefit SummariesSBC'sCertificate of Coverage (COC)
Premier 500 RX $8/$25/$60/$250Premier 500 RX $8/$25/$60/$250Premier 500
Premier 750 RX $8/$25/$60/$250Premier 750 RX $8/$25/$60/$250Premier 750
Premier 1500 RX $15/$35/$65/$250Premier 1500 RX $15/$35/$65/$250Premier 1500
Premier 2500 RX $15/$35/$65/$250Premier 2500 RX $15/$35/$65/$250Premier 2500
Premier 3000 RX $15/$35/$65/$250Premier 3000 RX $15/$35/$65/$250Premier 3000
Preferred 750 RX $15/$35/$65/$250Preferred 750 RX $15/$35/$65/$250Preferred 750
Preferred 1250 RX $15/$35/$65/$250Preferred 1250 RX $15/$35/$65/$250Preferred 1250
Preferred 1500 RX $15/$35/$65/$250Preferred 1500 RX $15/$35/$65/$250Preferred 1500
Preferred 2000 RX $15/$35/$65/$250Preferred 2000 RX $15/$35/$65/$250Preferred 2000
Preferred 3000 RX $15/$35/$65/$250Preferred 3000 RX $15/$35/$65/$250Preferred 3000
Consumer 1000 RX $15/$35/$65/$250Consumer 1000 RX $15/$35/$65/$250Consumer 1000
Consumer 2000 RX $15/$35/$65/$250Consumer 2000 RX $15/$35/$65/$250Consumer 2000
HSA 1750 RX $15/$35/$65/$250HSA 1750 RX $15/$35/$65/$250HSA 1750
HSA 2500 RX $15/$35/$65/$250HSA 2500 RX $15/$35/$65/$250HSA 2500
HSA 3000 RX $15/$35/$65/$250HSA 3000 RX $15/$35/$65/$250HSA 3000

RXMedical Travel Reimbursement Benefit
RX $8/$25/$60/$250 Overview

RX $15/$35/$65/$250 Policy

Reimbursement Request Form

Standard Insurance - Vision
VSP Links, Forms & Helpful InformationBenefit SummariesVSP Certificates
VSP WebsiteVSP Choice $10/$25VSP Signature $10/$25
VSP Provider LookupVSP Choice $10/$0
VSP Signature $10/$0
VSP - Out of Network Claim FormEye Med $10/$25Eye Med $10/$25
Eye Med Out of Network Claim Form

Choice Balance Care - Generic Eye Care Claim Reimbursement Form

Standard Insurance - 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

Ancillary Benefits & Programs
Life/AD&D Benefit Summaries: $10K, $20K, $30K, $40K, $50KLifeBalance FlyerPrior year summaries, forms, etc. available upon request to:
Life/AD&D Certificate (All Increments of Coverage)
Life Beneficiary Form

How to File a Life ClaimHealth Advocate
Life Claim FormTop Reasons to Call
AD&D Claim Form

Accelerated Death Benefits Claim Form