AGC Health Plan for Washington State

Group Administrator Links, Documents and Forms

Link to Online Administration Log-in Page Contact Customer Service
Carrier Forms: Health Net, Lifewise Assurance, VSP
Other: COBRA, Enrollment Forms, Flex Plan / Section 125, General Forms
Lifewise Assurance		Back to Top
Links	Plan Certificates	Plan Summary
Lifewise Assurance Website Administrative Forms Beneficiary Change Form AGC Group Life Claim Form	$10,000 Base Life/AD&D Certificate	Life/AD&D Plan Summary
Health Net		Back to Top
Links	Benefit Summaries (2006-7 Plan Year)	Benefit Summaries (2007-8 Plan Year)
HealthNet Website Provider Search Pharmacy Search Administrative Forms HIPAA Authorization Forms Express Scripts RX Mail Order Form RX Reimbursement Form Miscellaneous Summaries Pharmacy Disclosure Pharmacy Benefit Guide Domestic Partner Rider 24 Hour Coverage	PPO $250 PPO $500 PPO $750 PPO $1500 PPO $2500 RX $10/20/40 RX $10/50/50% RX $15/30/50% Plan Contract PPO Plan Contract HSA Qualified High Deductible Plans HSA $1500 Single / HSA $3000 Family HSA $2500 Single / HSA $5000 Family HSA RX 20% (included with all HDHP plans) Alternative Care Changes Effective January 1, 2007	PPO $250 PPO $300 PPO $500 PPO $750 PPO $1000 PPO $1500 PPO $2500 RX $10/$20/$40 RX $10/$50/$75 RX $15/$30/$50 Plan Contract HSA Qualified High Deductible Plans HSA $1500 Single / HSA $3000 Family HSA $2500 Single / HSA $5000 Family HSA RX 20% (included with all HDHP plans)
Vision Service Plan (VSP)		Back to Top
Links	Benefit Summaries (2006-7 Plan Year)	Benefit Summaries (2007-8 Plan Year)
VSP Website Provider Directory	Vision $10 / $25 Vision $0 / $10	Vision $10/$25 Vision $0/$10
Guardian
	Benefit Summaries (2008-9 Plan Year)
	Plan 1000 Plan 1000 With Ortho Plan 1500 Plan 1500 With Ortho Plan 2000 Plan 2000 With Ortho
COBRA – BenefitHelp Solutions		Back to Top
Administrative Guide	Administrative Agreement	Qualifying Event Notice Spreadsheet Initial Notice Template
Flex Plan		Back to Top
Flex Plan Overview Direct Deposit Form	Employee Enrollment Application Eligible Expenses	Employee Worksheet Premium Only Application (POP) (no cost 1^st year)
General Forms		Back to Top
Employee Enrollment Form Domestic Partner Affidavit Program Highlights Resources for Living EAP Flyer LifeBalance Program Flyer	Billing & Premium Process Billing & Monthly Premium Collection Delinquent Remittance Policies EFT Form, Terms & Conditions	Preferred Agent Network AGC of Washington AGC Inland Northwest