Members
Forms and Plan Documents
Benefits that support all aspects of your well-being
2025 Employee Benefits Guide
This guide provides an overview of your Adventist Health benefit options.
View the guide2025 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
2025 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
2025 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)
2025 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
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 - 2024 Forms and Plan Documents
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