School Forms and Publications

Arkansas State | Public School

School Employees

expand FormsPosted
2015 Active State & Public School Change Form9/11/2014
Affidavit of Spousal Health Care Coverage 8/8/2014
Authorization to Release Health Information2/8/2013
Datapath HSA Application & Salary Reduction Agreement | Plan Year 20149/24/2013
Datapath HSA Eligible & Non-Eligible Expenses | Plan Year 20158/27/2014
Datapath HSA Flyer | Plan Year 20158/27/2014
Minnesota Life Certificate of Coverage1/15/2014
Minnesota Life Evidence of Insurability Form12/13/2013
Notice of Termination and Retirement Form9/15/2014
expand Preferred Drug ListPosted
2014 PDL – Preferred Drug List6/17/2014
expand RatesPosted
2013 Plan Year | Active Employees | Effective 01/01/2013 1/9/2013
2014 Plan Year | Active | Effective 01/01/20141/15/2014
2015 Minnesota Life Rates | Active Employee | Effective 1/1/20158/19/2014
2015 Plan Year | Active Without Wellness Visit | Effective 01/01/20158/22/2014
2015 Plan Year | Cobra - Without Wellness Visit | Effective 01/01/20158/28/2014
expand Schedule of BenefitsPosted
2015 PSE Schedule of Benefits | Classic9/3/2014
2015 PSE Schedule of Benefits | Premium & Premium Retiree9/3/2014

School Retirees

expand FormsPosted
Affidavit of Spousal Health Care Coverage 8/8/2014
Bank Draft Authorization | updated 08/13/20136/10/2014
Minnesota Life Certificate of Coverage1/15/2014
Minnesota Life Portability Form3/11/2014
Retirement Health Enrollment Information & Instructions4/7/2014
expand Preferred Drug ListPosted
2013 PDL - Preferred Drug List1/2/2014
2015 PDL – Preferred Drug List9/16/2014
expand RatesPosted
2013 Plan Year | Medicare Retiree | Effective 01/01/2013 1/9/2013
2014 Minnesota Life Rates | Retiree | Effective 01/01/20141/17/2014
2014 Plan Year | Cobra | Effective 01/01/2014 10/1/2013
2014 Plan Year | Retiree | Effective 01/01/20141/15/2014
2015 Plan Year | Cobra - With Wellness Visit | Effective 01/01/20158/28/2014
2015 Plan Year | Medicare Primary Retirees | Effective 01/01/20158/4/2014
expand Schedule of BenefitsPosted
2015 PSE Schedule of Benefits | Basic9/3/2014
2015 PSE Schedule of Benefits | Medicare Primary Retiree9/3/2014
expand Summary Plan DescriptionsPosted
2013 Summary Plan Description1/2/2014
Spanish Summary of Benefits and Coverage - Bronze 2014 (Resumen de beneficios y cobertura - Bronce)10/28/2013
Spanish Summary of Benefits and Coverage - Silver 2014 (Resumen de beneficios y cobertura - Plata)12/23/2013
Summary of Benefits and Coverage - Gold 201412/23/2013

School Insurance Representatives

expand FormsPosted
Authorization to Release Health Information2/8/2013
Datapath HSA Application & Salary Reduction Agreement | Plan Year 20158/12/2014
Minnesota Life – Leave Without Pay Form8/18/2014
Non AASIS Matching Form11/28/2012
expand ManualsPosted
ARBenefits Task System Manual | Updated 02/13/1111/28/2012
Minnesota Life Administration Manual11/28/2012
Minnesota Life Summer Continuation6/14/2013
expand Preferred Drug ListPosted
2013 PDL - Preferred Drug List1/2/2014
2015 PDL – Preferred Drug List9/16/2014
expand RatesPosted
2014 Plan Year | Active | Effective 01/01/20141/15/2014
2015 Minnesota Life Rates | Active Employee | Effective 1/1/20158/19/2014
2015 Plan Year | Active With Wellness Visit | Effective 01/01/20158/22/2014
2015 Plan Year | Cobra - With Wellness Visit | Effective 01/01/20158/28/2014
2015 Plan Year | Medicare Primary Retirees | Effective 01/01/20158/4/2014
expand Schedule of BenefitsPosted
2015 PSE Schedule of Benefits | Basic9/3/2014
2015 PSE Schedule of Benefits | Medicare Primary Retiree9/3/2014
expand Summary Plan DescriptionsPosted
2013 Summary Plan Description1/2/2014
Spanish Summary of Benefits and Coverage - Bronze 2014 (Resumen de beneficios y cobertura - Bronce)10/28/2013
Spanish Summary of Benefits and Coverage - Silver 2014 (Resumen de beneficios y cobertura - Plata)12/23/2013
Summary of Benefits and Coverage - Gold 201412/23/2013