School Forms and Publications

Arkansas State | Public School

School Employees

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ARBenefits RX Member Reimbursement Form10/8/2014
Continuation of Dependent Coverage4/13/2016
HSA Verification Letter11/4/2014
Notice of Termination and Retirement Form10/7/2014
WageWorks PSE FAQ12/3/2015
Minnesota Life Enrollment & Change Form8/4/2015
2017 Active State and School Enrollment Election Form3/2/2017
DataPath Transfer of Assets6/2/2017
Minnesota Life - Beneficiary Designation and Change Request3/24/2017
Minnesota Life Conversion Form3/24/2017
Minnesota Life Evidence of Insurability Form3/24/2017
2018 Active State & Public School Change Form8/24/2017
2018 DataPath HSA Election Form10/31/2017
DataPath HSA Election Form8/18/2017
Minnesota Life - Beneficiary Designation and Change Request8/24/2017
Minnesota Life Conversion Form8/24/2017
Minnesota Life Evidence of Insurability Form8/24/2017
expand Preferred Drug List
2017 PDL – Preferred Drug List11/1/2017
expand Rates
2016 Plan Year | Active w/Wellness Visit | Effective 01/01/20168/14/2015
2016 Minnesota Life Rates | Active Employee | Effective 1/1/20169/23/2015
2017 Plan Year | Active w/Wellness Visit | Effective 01/01/20177/27/2016
2018 Plan Year | Active w/o Wellness Visit | Effective 01/01/2018 7/6/2017
2018 Plan Year | Cobra Rates | Effective 01/01/20187/6/2017
expand Schedule of Benefits
2016 PSE Schedule of Benefits - Classic9/1/2015
2017 PSE Schedule of Benefits - Basic3/14/2017
2017 PSE Schedule of Benefits - Premium8/22/2016
2018 PSE Schedule of Benefits - Classic12/12/2017
expand Summary Plan Descriptions
Summary of Benefits and Coverage - PSE Basic 20168/23/2016
Summary of Benefits and Coverage - PSE Premium 20168/23/2016
Summary of Benefits and Coverage - PSE Basic 201712/11/2017
Summary of Benefits and Coverage - PSE Premium 201712/11/2017

School Retirees

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Authorization to Release Health Information10/7/2014
Retiree Change of Address Form8/16/2016
Retirement Packet11/6/2017
2016 Retiree Dental and Vision Flyer10/1/2015
Minnesota Life Change Form8/4/2015
Minnesota Life - Beneficiary Designation and Change Request3/24/2017
Minnesota Life Change Form3/23/2017
Minnesota Life Retirement Deduction Authorization3/23/2017
expand Preferred Drug List
expand Rates
2016 Plan Year | Medicare Retiree | Effective 01/01/201612/1/2015
Minnesota Life Retiree Summary11/3/2015
2017 Plan Year | Non-Medicare Retiree | Effective 01/01/20177/27/2016
2018 Plan Year | Medicare Retiree | Effective 01/01/20187/6/2017
expand Schedule of Benefits
2016 PSE Schedule of Benefits - Basic9/1/2015
2016 PSE Schedule of Benefits - Medicare Primary Retiree1/5/2016
2017 PSE Schedule of Benefits - Basic3/14/2017
2017 PSE Schedule of Benefits - Medicare Primary Retiree8/22/2016
2018 PSE Schedule of Benefits - Basic9/20/2017
2018 PSE Schedule of Benefits - Medicare Primary Retiree9/20/2017

School Insurance Representatives

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PSE Summertime Portability Rules4/6/2017
Affidavit of Spousal Health Care Coverage 10/5/2017
Continuation of Coverage Form10/7/2014
Member Appeal Request Form11/17/2016
Notice of PSE Transfer4/30/2015
Minnesota Life – Leave Without Pay Form8/4/2015
WageWorks Employee Website Registration7/7/2016
WageWorks PSE HIR FAQ12/1/2015
Minnesota Life Portability Form3/24/2017
expand Manuals
IRS/SSA/CMS Data Match Book11/28/2012
Minnesota Life FAQs11/28/2012
expand Preferred Drug List
2017 PDL – Preferred Drug List11/1/2017
expand Rates
2016 Plan Year | Active w/Wellness Visit | Effective 01/01/20168/14/2015
2016 Plan Year | Non-Medicare Retiree | Effective 01/01/20168/14/2015
2017 Plan Year | Active w/Wellness Visit | Effective 01/01/20177/27/2016
2017 Plan Year | Non-Medicare Retiree | Effective 01/01/20177/27/2016
2018 Plan Year | Active w/Wellness Visit | Effective 01/01/20187/6/2017
2018 Plan Year | Non-Medicare Retiree | Effective 01/01/20187/6/2017
expand Schedule of Benefits
2016 PSE Schedule of Benefits - Classic9/1/2015
2017 PSE Schedule of Benefits - Basic3/14/2017
2017 PSE Schedule of Benefits - Premium8/22/2016