School Forms and Publications

Arkansas State | Public School

School Employees

expand Forms
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
2016 Active State and School Enrollment Election Form2/8/2016
HSA Account Terms, Conditions & Disclosures10/13/2015
Transfer of Assets3/23/2016
WageWorks HSA PowerPoint10/6/2015
Minnesota life - Beneficiary Designation and Change Request8/4/2015
Minnesota Life Conversion Form11/3/2015
Minnesota life Evidence of Insurability Form4/22/2016
2017 Active State & Public School Change Form3/2/2017
DataPath HSA Claim Form2/27/2017
DataPath Transfer of Assets12/30/2016
Minnesota Life - Beneficiary Designation and Change Request3/24/2017
Minnesota Life Conversion Form3/24/2017
Minnesota Life Evidence of Insurability Form3/24/2017
expand Preferred Drug List
2017 PDL – Preferred Drug List1/26/2017
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
expand Schedule of Benefits
2016 PSE Schedule of Benefits - Basic9/1/2015
2016 PSE Schedule of Benefits - Premium & Premium Retiree9/1/2015
2017 PSE Schedule of Benefits - Classic3/14/2017
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 20173/14/2017
Summary of Benefits and Coverage - PSE Premium 20171/24/2017

School Retirees

expand Forms
Authorization to Release Health Information10/7/2014
Retiree Change of Address Form8/16/2016
Retirement Packet8/11/2016
2016 Retiree Dental and Vision Flyer10/1/2015
Minnesota Life Certificate of Coverage8/4/2015
Minnesota Life Portability 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
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

School Insurance Representatives

expand Forms
PSE Summertime Portability Rules2/14/2017
Affidavit of Spousal Health Care Coverage 1/11/2017
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
Minnesota Life Portability 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 List1/26/2017
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
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