Adventist Health
  • Employee Health Plan
  • Contact Us
  • adventisthealth.org
Menu
  • Members
    • Members
    • Find a Provider
    • Member Resources
    • Member Login
    • Forms
    • Privacy/Legal Notices
  • Providers
    • Providers
    • Provider Login
    • Prior Authorization
    • Price Transparency – Machine Read Files
  • Search Site
Menu
Employee Health Plan Front Door Employee Health Plan Member Resources Employee Health Plan Benefits 2021 Documents and Forms

2021 Documents and Forms

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 of Benefits and Coverage (SBC) – Delano associates
  • Summary Plan Description (SPD)
  • Summary Plan Description (SPD) - AHRO and AHMC associates
  • Summary Plan Description (SPD) - Delano associates

Oregon Medical Benefits

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

Legal and Privacy notices

  • Omnibus
  • Privacy notice

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

  • Unavailable Service Request form
  • Medical Claim form
  • Pharmacy Claim form
  • Coordination of Benefits/Other Insurance form
  • General Authorization Designation of Personal Representation and Email Consent form

Employee Health Plan

Employee Health Plan
  • Member Resources
    • Employee Health Plan Benefits
      • 2022 Documents and Forms
      • 2021 Documents and Forms
    • Member Login
    • Eligibility/Enroll or Update Info
    • Diabetes Management Resources
    • Adventist Health OnDemand
    • Well-being Resources
    • Weight Management Programs
    • Inspire Newsletter
    • Other Benefits
    • Privacy Legal Notice
    • FAQs
    • Spiritual Care
  • Find a Provider
    • California Members
    • Oregon Members
    • All Other States Members
  • Contact Us
(800) 441-2524 Contact Us AdventistHealth.org
Adventist Health
(916) 406-0000
ONE Adventist Health Way
Roseville, CA 95661

Map + Directions
  • Privacy Policy
  • Compliance Information
  • Notice of Privacy Practices
  • Nondiscrimination Policy
  • Language Assistance Policy
  • No Surprises
Adventist Health ©2023
ONE Adventist Health Way, Roseville, CA 95661
x

⚠

Your browser is out of date. To get the full experience of this website, please update to most recent version.

Update My Browser
Search Site