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
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 Form8/4/2016
2017 WageWorks HSA Enrollment Form8/30/2016
HSA Bank Disclosure8/4/2016
WageWorks HSA Flyer8/24/2016
WageWorks PSE FAQ8/4/2016
Minnesota Life Certificate of Coverage8/4/2016
Minnesota Life Enrollment & Change Form8/4/2016
Minnesota Life Portability Form8/4/2016
expand Preferred Drug List
2017 PDL – Preferred Drug List (effective 1/1/2017)9/7/2016
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 - Classic9/1/2015
2017 PSE Schedule of Benefits - Basic8/22/2016
2017 PSE Schedule of Benefits - Premium8/22/2016
expand Summary Plan Descriptions
Summary of Benefits and Coverage - PSE Basic 20168/23/2016
Summary of Benefits and Coverage - PSE Premium 20168/23/2016

School Retirees

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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 Request8/4/2016
Minnesota Life Portability Form8/4/2016
expand Preferred Drug List
2017 PDL – Preferred Drug List (effective 1/1/2017)9/7/2016
expand Rates
2016 Plan Year | Non-Medicare Retiree | Effective 01/01/20168/14/2015
2017 Plan Year | 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 - Basic8/22/2016
2017 PSE Schedule of Benefits - Medicare Primary Retiree8/22/2016

School Insurance Representatives

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Affidavit of Spousal Health Care Coverage 8/11/2016
Continuation of Coverage Form10/7/2014
Member Appeal Request Form10/7/2014
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 Form8/4/2016
expand Manuals
IRS/SSA/CMS Data Match Book11/28/2012
Minnesota Life FAQs11/28/2012
expand Preferred Drug List
2016 PDL – Preferred Drug List9/7/2016
expand Rates
2016 Plan Year | Active w/o Wellness Visit | Effective 01/01/20168/14/2015
2016 Plan Year | Medicare Retiree | Effective 01/01/201612/1/2015
2017 Plan Year | Active w/o Wellness Visit | Effective 01/01/20177/27/2016
2017 Plan Year | 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 - Premium & Premium Retiree9/1/2015
2017 PSE Schedule of Benefits - Classic8/22/2016