School Forms and Publications

Arkansas State | Public School

School Employees

expand Forms
ARBenefits RX Member Reimbursement Form10/8/2014
Continuation Of Coverage10/7/2014
Member Appeal Request Form10/7/2014
2015 Active State and School Enrollment Election Form5/4/2015
Datapath HSA Claim Form | Plan Year 201510/6/2014
Datapath HSA FAQ's & Top 10 Reasons | Plan Year 201510/3/2014
Health Savings Account Verification11/6/2014
Minnesota Life Certificate of Coverage10/3/2014
Minnesota Life Enrollment & Change Form10/7/2014
Minnesota Life Portability Form10/7/2014
2016 Active State and School Enrollment Election Form2/8/2016
HSA Account Terms, Conditions & Disclosures10/13/2015
WageWorks HSA Flyer10/6/2015
WageWorks PSE FAQ12/3/2015
Minnesota Life Certificate of Coverage8/4/2015
Minnesota Life Enrollment & Change Form8/4/2015
Minnesota Life Portability Form8/4/2015
expand Preferred Drug List
2016 PDL – Preferred Drug List (Effective 1/1/2016)2/10/2016
expand Rates
2015 Plan Year | Active With Wellness Visit | Effective 01/01/201510/1/2014
2015 Plan Year | Cobra - With Wellness Visit | Effective 01/01/201510/1/2014
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
expand Schedule of Benefits
2015 PSE Schedule of Benefits | Classic9/1/2015
2015 PSE Schedule of Benefits | Premium & Premium Retiree9/1/2015
2016 PSE Schedule of Benefits - Classic9/1/2015
expand Summary Plan Descriptions
Summary of Benefits and Coverage - PSE Basic 2015 1/20/2015
Summary of Benefits and Coverage - PSE Premium 2015 1/20/2015
Summary of Benefits and Coverage - PSE Basic 20169/30/2015
Summary of Benefits and Coverage - PSE Premium 20169/30/2015

School Retirees

expand Forms
Affidavit of Spousal Health Care Coverage 10/7/2014
Bank Draft Authorization | updated 08/13/201310/7/2014
Minnesota life - Beneficiary Designation and Change Request6/22/2015
Minnesota Life Certificate of Coverage10/3/2014
Minnesota Life Portability Form10/7/2014
2016 Retiree Dental and Vision Flyer10/1/2015
Minnesota Life Certificate of Coverage8/4/2015
Minnesota Life Portability Form8/4/2015
expand Preferred Drug List
2015 PDL – Preferred Drug List12/29/2015
expand Rates
2015 Minnesota Life Rates | Retiree | effective 1/1/201510/1/2014
2015 Plan Year | Medicare Primary Retirees | Effective 01/01/201510/1/2014
2016 Plan Year | Medicare Retiree | Effective 01/01/201612/1/2015
Minnesota Life Retiree Summary11/3/2015
expand Schedule of Benefits
2015 PSE Schedule of Benefits | Classic9/1/2015
2015 PSE Schedule of Benefits | Premium & Premium Retiree9/1/2015
2016 PSE Schedule of Benefits - Classic9/1/2015
2016 PSE Schedule of Benefits - Premium & Premium Retiree9/1/2015

School Insurance Representatives

expand Forms
Affidavit of Spousal Health Care Coverage 10/7/2014
Continuation of Coverage Form10/7/2014
Member Appeal Request Form10/7/2014
Notice of PSE Transfer4/30/2015
Datapath HSA Application & Salary Reduction Agreement | Plan Year 201510/3/2014
Minnesota Life – Leave Without Pay Form10/3/2014
Minnesota Life – Leave Without Pay Form8/4/2015
Minnesota Life Portability Form8/4/2015
WageWorks PSE HIR FAQ12/1/2015
expand Manuals
IRS/SSA/CMS Data Match Book11/28/2012
Minnesota Life FAQs11/28/2012
expand Preferred Drug List
2015 PDL – Preferred Drug List12/29/2015
expand Rates
2015 Minnesota Life Rates | Active Employee | Effective 1/1/201510/1/2014
2015 Plan Year | Active With Wellness Visit | Effective 01/01/201510/1/2014
2015 Plan Year | Cobra - With Wellness Visit | Effective 01/01/201510/1/2014
2015 Plan Year | Non-Medicare Retiree| Effective 01/01/201510/1/2014
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
expand Schedule of Benefits
2015 PSE Schedule of Benefits | Classic9/1/2015
2015 PSE Schedule of Benefits | Premium & Premium Retiree9/1/2015
2016 PSE Schedule of Benefits - Classic9/1/2015