AGC Health Benefit Trust - Alaska Washington Chapters

AGC Health Benefit Trust - Washington Chapter
August 2016 - July 2017
Link to Online Administration (SIMON)
LINK TO 2015 FORMS & DOCUMENTS
AGC of Washington Website
Inland Northwest AGC 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 Intitial Notice Template (BSI Administers)Application

COBRA Initial Notice Template (BSI Does Not Administer)
HIPAA Release Form
2016 Medicare Part D - Cover LetterCDHP Administration Forms available upon request to:
2016 Medicare Part D - Credible Coverage Letterflexspending@bsitpa.com
2016 Medicare Part D - Non Credible Coverage Letter

United Healthcare - Medical/Rx
Links, Forms & Helpful InformationBenefit SummariesSBC's
UHC WebsitePremier 250Premier 250
Welcome to myUHCPremier 500Premier 500
Health4Me FlyerPremier 1000Premier 1000
EAP/Care 24Premier 1500Premier 1500
UHC Medical Claim FormPreferred 1000Preferred 1000
Flu Shot Reimbursement FormPreferred 2000Preferred 2000

Preferred 3000Preferred 3000

Preferred 5000Preferred 5000
OptumRx Mail-in Order FormNavigate 500Navigate 500
OptumRx Reimbursement FormNavigate 1000Navigate 1000
Navigate OverviewNavigate 1750Navigate 1750
Navigate FAQsNavigate 2500Navigate 2500
Navigate - Choosing a Primary Care PhysicianNavigate 3500Navigate 3500
HSA 1500HSA 1500
HSA 3500HSA 3500
Charter 500Charter 500
Charter 1000Charter 1000
Charter 1750Charter 1750
Charter 2500Charter 2500
Charter 3500Charter 3500
Rx $15/$40/$70/$250Certificates of coverage available upon request to:
Rx $15/$40/$70/$250 (HSA Plans)service@agchealthplansnw.com

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

Standard Vision
Links, Forms & Helpful InformationBenefit SummariesCertificates
Standard WebsitePlan $10/$0Plan $10/$0
Provider LookupPlan $10/$25Plan $10/$25
Vision Claim FormPlan $10/$0 (Voluntary)Plan $10/$0 (Voluntary)

Plan $10/$25 (Voluntary)Plan $10/$25 (Voluntary)

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, $50K
service@agchealthplansnw.com
Life/AD&D Certificate (All Increments of Coverage)
Life Beneficiary Form
How to File a Life Claim
Life Claim Form
AD&D Claim Form
Accelerated Death Benefits Claim Form