2023 Documents and Forms

2024 Benefits

Medical benefits

2023 Benefits at-a-Glance

2023 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
• In-house and 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
• Prior Authorization Matrix
• 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