State Forms and Publications

Arkansas State | Public School

State Employees

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Affidavit of Spousal Health Care Coverage 5/22/2017
Authorization to Release Health Information10/7/2014
Enrolling Online With ARBenefits8/15/2017
Member Appeal Request Form11/17/2016
2017 Active State and School Enrollment Election Form3/2/2017
Delta Dental Enrollment & Change Form8/4/2016
Delta Dental Premium Plan Child Ortho8/4/2016
2017 DataPath FSA Election Form12/12/2016
DataPath Transfer of Assets6/2/2017
Humana Vision Booklet with Application | Plan Year 20179/8/2016
Minnesota Life Certificate of Coverage3/24/2017
Minnesota Life Enrollment & Change Form8/9/2017
Minnesota Life LWOP, FMLA, & Worker's Comp Form3/23/2017
2018 Delta Dental Enrollment Form8/15/2017
Delta Carryover Benefit8/15/2017
Humana Vision Benefits and application 20188/15/2017
DataPath FSA Claim Form8/18/2017
DataPath HSA Election Form8/18/2017
Minnesota life Beneficiary Designation Form8/15/2017
Minnesota Life Conversion Form8/24/2017
Minnesota Life Evidence of Insurability Form8/24/2017
Minnesota Life Portability Form8/24/2017
expand Preferred Drug List
expand Rates
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
2018 Plan Year | Active w/o Wellness Visit | Effective 01/01/20187/6/2017
2018 Plan Year | Cobra Rates | Effective 01/01/20187/6/2017
expand Schedule of Benefits
2017 ASE Schedule of Benefits - Basic8/22/2017
2017 ASE Schedule of Benefits - Premium8/22/2017
2018 ASE Schedule of Benefits - Classic9/20/2017
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 Packet5/22/2017
2016 Retiree Dental and Vision Flyer10/1/2015
Minnesota Life Retirement Deduction Authorization11/3/2015
Minnesota Life Certificate of Coverage3/24/2017
Minnesota Life Portability Form3/24/2017
expand Preferred Drug List
2017 PDL – Preferred Drug List8/28/2017
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
Minnesota Life Retiree Summary3/23/2017
2018 Plan Year | Non-Medicare Retiree | Effective 01/01/2018 7/6/2017
expand Schedule of Benefits
2017 ASE Schedule of Benefits - Basic8/22/2017
2017 ASE Schedule of Benefits - Premium8/22/2017
2018 ASE Schedule of Benefits - Basic9/20/2017
2018 ASE Schedule of Benefits - Medicare Primary Retiree 9/20/2017

State Insurance Representatives

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Affidavit of Spousal Health Care Coverage 5/22/2017
Authorization to Release Health Information10/7/2014
Continuation of Coverage Form10/7/2014
Non AASIS Matching Form10/7/2014
Refund Request - State | Updated 08/31/200710/7/2014
Minnesota Life – Leave Without Pay Form8/4/2015
Minnesota Life Conversion Form3/24/2017
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
2017 PDL – Preferred Drug List8/28/2017
expand Rates
2016 Plan Year | Active w/Wellness Visit | Effective 01/01/20168/14/2015
2016 Plan Year | Non-Medicare Retiree | Effective 01/01/20168/14/2015
2017 Plan Year | Active w/Wellness Visit | Effective 01/01/20178/16/2016
2017 Plan Year | Non-Medicare Retiree | Effective 01/01/20178/16/2016
2018 Plan Year | Active w/Wellness Visit | Effective 01/01/20187/6/2017
2018 Plan Year | Non-Medicare Retiree | Effective 01/01/2018 7/6/2017
expand Schedule of Benefits
2017 ASE Schedule of Benefits - Classic8/22/2017