AGC Health Benefit Trust - Alaska Washington Chapters

AGC Health Benefit Trust - Alaska Chapter
June 2016 - May 2017
Link to Online Administration (SIMON)
AGC of Alaska Website

Program Overview

Quoting Materials

Submission Materials
OverviewQuote Request FormSubmission Checklist
Product GridCensus TemplateEmployer Application
Underwriting GuidelinesEmployee Enrollment Form
Member Contact InformationEnrollment Census Template
BSI Administrative GuideSBC Acknowledgement Form
Late Submission Letter

EFT Authorization Form

BSI COBRA Administrative Agreement

Compliance Resources

Dollar Bank

Section 125/CDHP Administration
Summary Plan DescriptionOverviewSection 125 Adoption Agreement
Privacy Notice to MembersPolicySection 125 Non-Discrimination Testing
COBRA Initial Notice Template (BSI Administers)Application

COBRA Initial Notice Template (BSI Does Not Administer)
HIPAA Release FormCDHP Administration Forms available upon request to:
2016 Medicare Part D - Credible Coverage

United Healthcare - Medical/Rx
Links, Forms & Helpful Information
UHC WebsiteUHC Medical Claim FormHealth4Me Flyer
Welcome to myUHCFlu Shot Reimbursement FormEAP/Care 24

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
RX $8/$25/$60/$250 
RX $15/$35/$65/$250 
RX $15/$35/$65/$250 (HSA Plans)

Standard Insurance - Vision
VSP Links, Forms & Helpful InformationBenefit SummariesVSP Certificates
VSP WebsiteVSP Signature $10/$25VSP Signature $10/$25
VSP Provider LookupVSP Signature $10/$0
VSP Signature $10/$0
VSP - Out of Network Claim FormEye Med $10/$25Eye Med $10/$25
Eye Med Out of Network Claim FormChoice Reimbursement Benefit SummaryChoice Reimbursement Certificate
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
United Healthcare Life/AD&D Benefit OverviewLifeBalance FlyerPrior year summaries, forms, etc. available upon request to:
Life/AD&D Benefit Summaries: $10K, $20K, $30K, $40K, $50KCoPatient
Life/AD&D Certificate (All Increments of Coverage)
Life Beneficiary FormHealth Advocate
How to File a Life ClaimTop Reasons to Call
Life Claim Form
AD&D Claim Form
Accelerated Death Benefits Claim Form