State Forms and Publications

Arkansas State | Public School

State Employees

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ARBenefits RX Member Reimbursement Form10/8/2014
Continuation of Dependent Coverage4/13/2016
HSA Verification Letter11/4/2014
2016 Active State & Public School Change Form2/8/2016
Delta Dental Base Plan Summary8/26/2015
Delta Dental Plan Comparison Sheet | Plan Year 20168/20/2015
Delta Dental Premium Plan Summary8/26/2015
2016 WageWorks HSA Enrollment Form10/12/2015
HSA Account Terms, Conditions & Disclosures10/13/2015
Transfer of Assets3/23/2016
WageWorks FSA Flyer10/6/2015
WageWorks HSA Flyer10/6/2015
Humana Vision Booklet with Application | Plan Year 20168/20/2015
Minnesota Life Certificate of Coverage8/4/2015
Minnesota Life Enrollment & Change Form8/4/2015
Minnesota Life LWOP, FMLA, & Worker's Comp Form3/23/2017
2017 Active State & Public School Change Form3/2/2017
Delta Dental Base Plan Summary8/4/2016
Delta Dental Plan Comparison Sheet | Plan Year 20178/4/2016
Delta Dental Premium Plan Summary8/4/2016
DataPath FSA Claim Form2/27/2017
DataPath HSA Election Form12/12/2016
DataPath Transition FAQ12/7/2016
Minnesota life Beneficiary Designation Form3/24/2017
Minnesota Life Conversion Form3/24/2017
Minnesota Life Evidence of Insurability Form3/24/2017
Minnesota Life Portability Form3/24/2017
expand Preferred Drug List
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2016 Plan Year | Active w/o Wellness Visit | Effective 01/01/20168/14/2015
2016 Plan Year | Cobra Rates | Effective 01/01/201612/22/2015
Minnesota Life Summary11/3/2015
2017 Plan Year | Active w/Wellness Visit | Effective 01/01/20178/16/2016
expand Schedule of Benefits
2016 ASE Schedule of Benefits - Basic9/1/2015
2016 ASE Schedule of Benefits - Premium & Premium Retiree5/24/2016
2017 ASE Schedule of Benefits - Classic3/14/2017
expand Summary Plan Descriptions
Summary of Benefits and Coverage - ASE Basic 20168/23/2016
Summary of Benefits and Coverage - ASE Premium 20161/4/2017
Summary of Benefits and Coverage - ASE Basic 20173/14/2017
Summary of Benefits and Coverage - ASE Premium 20171/24/2017
expand Table of Important Dates
2017 Table of Important Dates12/12/2016

State 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 Form3/24/2017
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 01/01/20168/14/2015
Minnesota Life Retiree Summary11/3/2015
2017 Plan Year | Non-Medicare Retiree | Effective 01/01/20178/16/2016
expand Schedule of Benefits
2016 ASE Schedule of Benefits - Medicare Primary Retiree1/5/2016
2016 ASE Schedule of Benefits - Classic9/1/2015
2017 ASE Schedule of Benefits - Basic3/14/2017
2017 ASE Schedule of Benefits - Premium8/22/2016

State Insurance Representatives

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Affidavit of Spousal Health Care Coverage 1/11/2017
Billing Recap (Retirees)10/7/2014
Member Appeal Request Form11/17/2016
Non-AASIS Notice of Termination & Retirement Form10/7/2014
Request to Remove IT168-Life and IT377-Misc. Plans2/5/2015
Minnesota Life Conversion Form11/3/2015
WageWorks ASE 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
State Health Insurance Representative Forms Routing Information Sheet3/14/2017
expand Preferred Drug List
expand Rates
2016 Plan Year | Active w/o Wellness Visit | Effective 01/01/20168/14/2015
2016 Plan Year | Medicare Retiree | Effective 01/01/20168/14/2015
2017 Plan Year | Active w/o Wellness Visit | Effective 01/01/20178/16/2016
2017 Plan Year | Medicare Retiree | Effective 01/01/20177/27/2016
expand Schedule of Benefits
2016 ASE Schedule of Benefits - Basic9/1/2015
2016 ASE Schedule of Benefits - Premium & Premium Retiree5/24/2016
2017 ASE Schedule of Benefits - Classic3/14/2017