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
Member Appeal Request Form10/7/2014
Datapath HSA Application & Salary Reduction Agreement | Plan Year 201410/3/2014
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
expand Preferred Drug List
2014 PDL – Preferred Drug List6/17/2014
expand Rates
2013 Plan Year | Active Employees | Effective 01/01/2013 10/1/2014
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 | Active Without Wellness Visit | Effective 01/01/201510/1/2014
expand Schedule of Benefits
2015 PSE Schedule of Benefits | Basic9/3/2014
2015 PSE Schedule of Benefits | Medicare Primary Retiree9/3/2014
expand Summary Plan Descriptions
Spanish Summary of Benefits and Coverage - Bronze 2014 (Resumen de beneficios y cobertura - Bronce)1/14/2015
Spanish Summary of Benefits and Coverage - Silver 2014 (Resumen de beneficios y cobertura - Plata)1/14/2015
Summary of Benefits and Coverage - Gold 20141/14/2015
ARBenefits Summary Plan Description6/22/2015
Summary of Benefits and Coverage - PSE Classic 2015 1/20/2015

School Retirees

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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
expand Preferred Drug List
2014 PDL – Preferred Drug List6/17/2014
expand Rates
2013 Plan Year | Cobra | Effective 01/01/2013 10/1/2014
2013 Plan Year | Retiree | Effective 01/01/2013 10/1/2014
2014 Plan Year | Act 331 | Effective 01/01/201410/1/2014
2014 Plan Year | Medicare Retiree | Effective 01/01/201410/1/2014
2015 Minnesota Life Rates | Retiree | effective 1/1/201510/1/2014
2015 Plan Year | Medicare Primary Retirees | Effective 01/01/201510/1/2014
expand Schedule of Benefits
2015 PSE Schedule of Benefits | Basic9/3/2014
2015 PSE Schedule of Benefits | Medicare Primary Retiree9/3/2014
expand Summary Plan Descriptions
Spanish Summary of Benefits and Coverage - Bronze 2014 (Resumen de beneficios y cobertura - Bronce)1/14/2015
Spanish Summary of Benefits and Coverage - Silver 2014 (Resumen de beneficios y cobertura - Plata)1/14/2015
Summary of Benefits and Coverage - Gold 20141/14/2015
ARBenefits Summary Plan Description6/22/2015

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
expand Manuals
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 List
2014 PDL – Preferred Drug List6/17/2014
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 Minnesota Life Rates | Retiree | effective 1/1/201510/1/2014
2015 Plan Year | Active Without Wellness Visit | Effective 01/01/201510/1/2014
2015 Plan Year | Medicare Primary Retirees | Effective 01/01/201510/1/2014
expand Schedule of Benefits
2015 PSE Schedule of Benefits | Basic9/3/2014
2015 PSE Schedule of Benefits | Medicare Primary Retiree9/3/2014
expand Summary Plan Descriptions
Spanish Summary of Benefits and Coverage - Bronze 2014 (Resumen de beneficios y cobertura - Bronce)1/14/2015
Spanish Summary of Benefits and Coverage - Silver 2014 (Resumen de beneficios y cobertura - Plata)1/14/2015
Summary of Benefits and Coverage - Gold 20141/14/2015
ARBenefits Summary Plan Description6/22/2015