School Forms and Publications

Arkansas State | Public School

School Employees

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ARBenefits RX Member Reimbursement Form10/8/2014
Continuation Of Coverage10/7/2014
Notice of Termination and Retirement Form10/7/2014
Datapath HSA Application & Salary Reduction Agreement | Plan Year 201410/3/2014
2015 Active State and School Enrollment Election Form10/7/2014
Datapath HSA Claim Form | Plan Year 201510/6/2014
Datapath HSA FAQ's & Top 10 Reasons | Plan Year 201510/3/2014
Minnesota Life Certificate of Coverage10/3/2014
Minnesota Life Evidence of Insurability Form10/7/2014
expand Preferred Drug List
2013 PDL - Preferred Drug List1/2/2014
2015 PDL – Preferred Drug List9/17/2014
expand Rates
2014 Plan Year | Act 331 | Effective 01/01/201410/1/2014
2014 Plan Year | Cobra | Effective 01/01/2014 10/1/2014
2015 Plan Year | Act 331 | Effective 01/01/201510/1/2014
2015 Plan Year | Active Without Wellness Visit | Effective 01/01/201510/1/2014
2015 Plan Year | Cobra - Without Wellness Visit | Effective 01/01/201510/1/2014
expand Schedule of Benefits
2015 PSE Schedule of Benefits | Classic9/3/2014
2015 PSE Schedule of Benefits | Premium & Premium Retiree9/3/2014
expand Summary Plan Descriptions
2014 Summary Plan Description7/23/2014
Spanish Summary of Benefits and Coverage - Bronze 2014 (Resumen de beneficios y cobertura - Bronce)10/28/2013
Spanish Summary of Benefits and Coverage - Gold 2014 (Resumen de beneficios y cobertura - Oro)12/23/2013
Spanish Summary of Benefits and Coverage - Silver 2014 (Resumen de beneficios y cobertura - Plata)12/23/2013
Summary of Benefits and Coverage - Bronze 201410/2/2013
Summary of Benefits and Coverage - Gold 201412/23/2013
Summary of Benefits and Coverage - Silver 201412/23/2013

School Retirees

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Authorization to Release Health Information10/7/2014
Retirement Election Packet10/7/2014
Retirement Health Enrollment Information & Instructions10/7/2014
Minnesota Life Arkansas Retirement Deduction Authorization10/14/2014
Minnesota Life Change Form | effective 01/01/201310/3/2014
expand Preferred Drug List
2013 PDL - Preferred Drug List1/2/2014
2015 PDL – Preferred Drug List9/17/2014
expand Rates
2013 Plan Year | Medicare Retiree | Effective 01/01/2013 10/1/2014
2014 Minnesota Life Rates | Retiree | Effective 01/01/201410/1/2014
2014 Plan Year | Cobra | Effective 01/01/2014 10/1/2014
2014 Plan Year | Retiree | Effective 01/01/201410/1/2014
2015 Plan Year | Act 331 | Effective 01/01/201510/1/2014
2015 Plan Year | Cobra - Without Wellness Visit | Effective 01/01/201510/1/2014
2015 Plan Year | Non-Medicare Retiree| Effective 01/01/201510/1/2014
expand Schedule of Benefits
2015 PSE Schedule of Benefits | Classic9/3/2014
2015 PSE Schedule of Benefits | Premium & Premium Retiree9/3/2014
expand Summary Plan Descriptions
2014 Summary Plan Description7/23/2014
Spanish Summary of Benefits and Coverage - Gold 2014 (Resumen de beneficios y cobertura - Oro)12/23/2013
Summary of Benefits and Coverage - Bronze 201410/2/2013
Summary of Benefits and Coverage - Silver 201412/23/2013

School Insurance Representatives

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Authorization to Release Health Information10/7/2014
Member Appeal Request Form10/7/2014
Notice of Termination and Retirement Form10/7/2014
Datapath HSA Claim Form | Plan Year 201510/6/2014
Minnesota Life Portability Form10/7/2014
expand Manuals
IRS/SSA/CMS Data Match Book11/28/2012
Minnesota Life FAQs11/28/2012
expand Preferred Drug List
2013 PDL - Preferred Drug List1/2/2014
2015 PDL – Preferred Drug List9/17/2014
expand Rates
2014 Plan Year | Active | Effective 01/01/201410/1/2014
2015 Minnesota Life Rates | Active Employee | Effective 1/1/201510/1/2014
2015 Plan Year | Act 331 | Effective 01/01/201510/1/2014
2015 Plan Year | Active Without Wellness Visit | Effective 01/01/201510/1/2014
2015 Plan Year | Cobra - Without Wellness Visit | Effective 01/01/201510/1/2014
2015 Plan Year | Non-Medicare Retiree| Effective 01/01/201510/1/2014
expand Schedule of Benefits
2015 PSE Schedule of Benefits | Classic9/3/2014
2015 PSE Schedule of Benefits | Premium & Premium Retiree9/3/2014
expand Summary Plan Descriptions
2014 Summary Plan Description7/23/2014
Spanish Summary of Benefits and Coverage - Gold 2014 (Resumen de beneficios y cobertura - Oro)12/23/2013
Summary of Benefits and Coverage - Bronze 201410/2/2013
Summary of Benefits and Coverage - Silver 201412/23/2013