Forms and Plan Documents
Benefits that support all aspects of your well-being
2026 Employee Benefits Guide
This guide provides an overview of your Adventist Health benefit options.
View the guide2026 Employee Health Plan Benefits
- Employee Health Plan Side-by-Side Comparisons
- Employee Health Plan Summary of Benefits and Coverage (SBC)
- High Deductible Health Plan Summary of Benefits and Coverage (SBC)
- Employee Health Plan Summary Plan Description (SPD) - All
- Employee Health Plan Summary Plan Description (SPD) - AHMC, AHRO, AHCG
- High-Deductible Health Plan Summary Plan Description (SPD) - All
- High-Deductible Health Plan Summary Plan Description (SPD) - AHMC, AHRO, AHCG
Legal and Privacy notices
Pharmacy benefits
Important Update to Your Pharmacy Benefits
Starting January 1, 2026, your pharmacy benefit manager will transition from OptumRx to MedImpact. MedImpact’s home delivery pharmacy is Birdi. If you currently receive prescriptions by mail from OptumRx, any remaining refills will automatically transfer to Birdi after the change. Visit MedImpact’s website or call them directly after Jan. 1, 2026, for additional information. Be sure to review the documents below for updated benefit information.
- Zero Dollar Copay Medication List
- In-House and Community Partner Pharmacy List
- MedImpact Claim Form
- MedImpact Prior Authorization Request Form
- Pharmacy Benefit
- Free Glucose Meter
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
Bariatric Surgery
Flexible Spending Account
For additional information:
Visit: EBCFlex.com
Call: 800-346-2126
Health Savings Account
For additional information:
Visit: Myfidelitysite.com/AdventistHealthHSA
Call: 800-343-0860
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
2022 - 2025 Forms and Plan Documents
2025 Forms and Plan Documents
California Medical Benefits
- CA Side-by-Side Benefit Comparison
- CA Summary of Benefits and Coverage (SBC)
- CA Summary Plan Description (SPD)
- Balance Bill Resource Guide
AHRO & AHMC Medical Benefits
- AHRO & AHMC - Side-by-Side Benefit Comparison
- AHRO & AHMC - Summary of Benefits and Coverage (SBC)
- AHRO & AHMC - Summary Plan Description (SPD)
- Balance Bill Resource Guide
Outside of California Medical Benefits
- Outside of CA Side-by-Side Benefit Comparison
- Outside of CA Summary of Benefits and Coverage (SBC)
- Outside of CA Summary Plan Description (SPD)
AHCG Medical Benefits
- AHCG - Side-by-Side Benefit Comparison
- AHCG - Summary of Benefits and Coverage (SBC)
- AHCG - Summary Plan Description (SPD)
Legal and Privacy notices
Pharmacy benefits
- Pharmacy Benefit
- Zero Dollar Copay Medication List
- In-house and Community Partner Pharmacy List
- OptumRx Formulary
- OptumRx Claim Form
- OptumRx website and app brochure
- 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
Bariatric Surgery
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
2024 Forms and Plan Documents
California Medical Benefits
- Side-by-Side Benefit Comparison
- Summary of Benefits and Coverage (SBC)
- Summary Plan Description (SPD)
- AHRO & AHMC - Summary of Benefits and Coverage (SBC)
- AHRO & AHMC - Summary Plan Description (SPD)
- Balance Bill Resource Guide
Medical Benefits for Members Outside of California
- Side-by-Side Benefit Comparison
- Summary of Benefits and Coverage (SBC)
- Summary Plan Description (SPD)
- AHCG - Summary of Benefits and Coverage (SBC)
- AHCG - Summary Plan Description (SPD)
Legal and Privacy notices
Pharmacy benefits
- Pharmacy Benefit
- Zero Dollar Copay Medication List
- In-house and Community Partner Pharmacy List
- OptumRx Formulary
- OptumRx Claim Form
- OptumRx website and app brochure
- 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
2023 Forms and Plan Documents
Medical benefits
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
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
2022 Forms and Plan Documents
Medical benefits
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
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