Benefits Plan Document and Summaries
Medical Benefit Summaries Effective 1/1/2019
Medical Schedule of Benefits $500 Deductible Plan
Medical Schedule of Benefits $750 Deductible Plan
Medical Schedule of Benefits $1,000 Deductible Plan
Medical Schedule of Benefits $2,000 Deductible Plan
Medical Schedule of Benefits $5,000 Deductible Plan
Medical Schedule of Benefits $5,000 Deductible Plan-HSA
Medical Benefit Summaries Effective 6/1/2018 through 12/31/2018
Medical Schedule of Benefits $500 Deductible Plan
Medical Schedule of Benefits $750 Deductible Plan
Medical Schedule of Benefits $1,000 Deductible Plan
Medical Schedule of Benefits $2,000 Deductible Plan
Medical Schedule of Benefits $5,000 Deductible Plan
Medical Schedule of Benefits $5,000 Deductible Plan-HSA
Medical Benefit Summaries Prior to 6/1/2018
Medical Schedule of Benefits $500 Deductible Plan
Medical Schedule of Benefits $750 Deductible Plan
Medical Schedule of Benefits $1,000 Deductible Plan
Medical Schedule of Benefits $2,000 Deductible Plan
Medical Schedule of Benefits $5,000 Deductible Plan
Medical Schedule of Benefits $5,000 Deductible Plan-HSA
Prescription Drug Benefit Summaries Effective 1/1/2019
Prescription Drug Schedule of Benefits 10/20/50 Copay Plan
Prescription Drug Schedule of Benefits 15/25/60 Copay Plan
Prescription Drug Schedule of Benefits 20/35/75 Copay Plan
Prescription Drug Benefit Summaries Prior to 1/1/2019
Prescription Drug Schedule of Benefits 10/20/50 Copay Plan
Prescription Drug Schedule of Benefits 15/25/60 Copay Plan
Prescription Drug Schedule of Benefits 20/35/75 Copay Plan
AgBenefits Vision Plan Summary
AgBenefits Vision Plan Summary
Dental Summary
AgBenefits Dental Plan Schedule
Forms
AgBenefits Request For Proposal
AgBenefits Health Statement Long Form
AgBenefits Health Statement Short Form
AgBenefits Medical Group Application
AgBenefits Enrollment/Termination/Change Form
AgBenefits Diabetic Program Order Form
Prescription Mail Order Form
Medical Claims Transmittal Form
Vision Claim Form
AgBenefits Dental Group Application
AgBenefits Dental Claim Form
Bentegrity PHI Release