2022 Documents and Forms

Medical benefits

2022 Benefits at-a-Glance

2022 Benefits Guide

California Medical Benefits

• Side by side benefit comparison
• Summary of Benefits and Coverage (SBC)
• Summary of Benefits and Coverage (SBC) – AHRO and AHMC associates
• Summary Plan Description (SPD)
• Summary Plan Description (SPD) - AHRO and AHMC associates

Medical Benefits for Members Outside of California

• Side by side benefit comparison
• Summary of Benefits and Coverage (SBC)
• Summary Plan Description (SPD)

Legal and Privacy notices

• Omnibus
• Privacy notice
• Balance Billing Disclosure

Global Emergency Services

• Global Emergency Services

Pharmacy benefits

• Pharmacy Benefit
• Zero Dollar Copay Medication List
• Community Partner Pharmacy List
• OptumRx Formulary
• OptumRx Claim Form
• How to create an OptumRx account
• Preventive Care Medications
• Free glucose monitor

Forms

• Prior Authorization/Unavailable Services Request form
• Medical Claim form
• OptumRx Claim Form
• Coordination of Benefits/Other Insurance form
• General Authorization Designation of Personal Representation and Email Consent form

Flexible Spending Account

For claims and additional information:

• Visit EBCFlex.com
• Call 800-346-2126

Dental

For claims and additional information:

• Visit DeltaDentalins.com/AH
• Call 888-335-8227

Vision

For claims and additional information:

• Visit Adventist.VSPForMe.com
• Call 800-877-7195