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Arkansas State

Arkansas State | Public School

State Employees

 
Forms:  
     ARBenefits:  
             2019 Open Enrollment Guide 10/02/2018
             Affidavit of Spousal Health Care Coverage 10/5/2017
             ARBenefits RX Member Reimbursement Form 10/8/2014
             Authorization to Release Health Information 10/7/2014
             Continuation of Dependent Coverage 4/13/2016
             Enrolling Online With ARBenefits 8/15/2017
             Member Appeal Request Form 01/19/2018
             AR Benefits Primary Care Provider Form 04/27/2018
       2019:  
             ARBenefits:  
                        2019 Active State & Public School Change Form 09/19/2018
                        2019 Active State and School Enrollment Election Form  09/19/2018
             HSA/FSA  
                        Connect Your Care FSA Enrollment Form 11/20/2018
                        Connect Your Care HSA Enrollment Form 09/24/2018
                        CYC Transfer of Assets Form 12/03/2018
             ARSEBA:  
                        2019 Delta Dental Enrollment Form 09/19/2018
                        2019 Delta Dental plan Comparison  09/19/2018
                        2019 Humana Vision Benefit Summary 09/19/2018
                        Humana Vision Benefits and application 2019 09/19/2018
             Securian:  
                        Minnesota life Beneficiary Designation Form 09/19/2018
                        Minnesota Life Certificate of Coverage 09/19/2018
                        Minnesota Life Conversion Form 09/19/2018
                        Minnesota Life Enrollment & Change Form 09/19/2018
                        Minnesota Life Evidence of Insurability Form 09/19/2018
                        Minnesota Life LWOP, FMLA, & Worker's Comp Form 09/19/2018
                        Minnesota Life Portability Form 09/19/2018
   
      2018:  
           ARBenefits:  
                      2018 Active State & Public School Change Form 08/09/2018
                      2018 Active State and School Enrollment Election Form 03/02/2018
           ARSEBA:  
                    2018 Delta Dental Enrollment Form 8/15/2017
                   2018 Delta Dental plan comparison 8/15/2017
                   AirMedCare 10/24/2017
                   Delta Carryover Benefit 8/15/2017
                   Flyer for Voluntary Benefits - 2018 8/15/2017
                   Humana Vision Benefits and application 2018 8/15/2017
                   Identity Guard Flier 10/24/2017
           HSA/FSA:  
                  2018 DataPath FSA Election Form 8/18/2017
                  2018 DataPath HSA Election Form 03/12/2018
                  DataPath FSA Claim Form 8/18/2017
                  DataPath HSA Claim Form 8/18/2017
                 DataPath Transfer of Assets 8/18/2017
           Securian:  
                  Minnesota life Beneficiary Designation Form 8/15/2017
                 Minnesota Life Certificate of Coverage 8/24/2017
                 Minnesota Life Conversion Form 8/24/2017
                 Minnesota Life Enrollment & Change Form 07/27/2018
                 Minnesota Life Evidence of Insurability Form 8/24/2017
                 Minnesota Life LWOP, FMLA, & Worker's Comp Form 8/15/2017
                 Minnesota Life Portability Form 8/24/2017
   
Preferred Drug List:  
           2018:  
                    2018 PDL – Preferred Drug List 06/12/2018
Rates:  
           2018:  
                    2018 Plan Year | Active w/o Wellness Visit | Effective 01/01/2018 07/6/2017
                    2018 Plan Year | Active w/Wellness Visit | Effective 01/01/2018 07/6/2017
                    2018 Plan Year | Cobra Rates | Effective 01/01/2018 07/6/2017
                    Securian Life Summary 09/17/2018
   
            Minnesota Life:  
                     Minnesota Life Retiree Summary 11/3/2015
                      Minnesota Life Summary 11/3/2015
   
Schedule of Benefits:  
              2019  
                      2019 ASE Schedule of Benefits - Basic 09/24/2018
                      2019 ASE Schedule of Benefits - Classic 11/30/2018
                      2019 ASE Schedule of Benefits - Premium 09/24/2018
              2018:  
                      2018 ASE Schedule of Benefits - Basic 02/27/2018
                      2018 ASE Schedule of Benefits - Classic 02/27/2018
                      2018 ASE Schedule of Benefits - Premium 02/27/2018
   
Summary Plan Descriptions:  
              2018:  
                        2018 ARBenefits Summary Plan Description (effective 1/1/18) 04/27/2018
                        Summary of Benefits and Coverage - ASE Basic 2018 04/27/2018
                        Summary of Benefits and Coverage - ASE Classic 2018 04/27/2018
                        Summary of Benefits and Coverage - ASE Premium 2018 04/27/2018
   
Table of Important Dates:  
                2018:  
                          2018 Table of Important Dates 09/27/2017
                 

State Retirees

 
Forms:  
               ARBenefits:  
                         Affidavit of Spousal Health Care Coverage 10/5/2017
                         Authorization to Release Health Information 10/7/2014
                         Bank Draft Authorization | updated 08/13/2013 10/7/2014
                         Retiree Change of Address Form 08/16/2016
                         Retirement Health Enrollment Information & Instructions 03/30/2017
                         Retirement Packet 12/05/2018
                         2018:  
                            Securian:  
                             Minnesota life Beneficiary Designation Form 01/04/2018
                             Minnesota Life Certificate of Coverage 01/04/2018
                             Minnesota Life Change Form 01/04/2018
                             Minnesota Life Portability Form 01/04/2018
                             Minnesota Life Retirement Deduction Authorization 01/04/2018
                             Delta Dental:  
                             2018 Retiree Dental and Vision Brochure 01/04/2018
   
Preferred Drug List:  
                       2018:  
                              2018 PDL – Preferred Drug List 07/17/2018
Rates:  
                       2018:  
                               2018 Plan Year | Medicare Retiree | Effective 01/01/2018 07/6/2017
                               2018 Plan Year | Non-Medicare Retiree | Effective 01/01/2018 03/01/2018
   
Schedule of Benefits:  
                       2019:  
                                  2019 ASE Schedule of Benefits - Basic 12/05/2018
                                  2019 ASE Schedule of Benefits - Classic 12/05/2018
                                  2019 ASE Schedule of Benefits - Premium 12/05/2018
                                  2019 ASE Schedule of Benefits - Medicare Primary Retiree 12/05/2018
                        2018:  
                                 2018 ASE Schedule of Benefits - Basic 09/20/2017
                                 2018 ASE Schedule of Benefits - Classic 01/25/2018
                                 2018 ASE Schedule of Benefits - Medicare Primary Retiree 02/09/2018
                                 2018 ASE Schedule of Benefits - Premium 01/25/2018
                          

State Insurance Representatives

 
Forms:  
                       AR Diamond Plan Opt-Out Form 10/13/2016
                        ARBenefits:  
                                     Affidavit of Spousal Health Care Coverage 10/5/2017
                                     ASE Benefits Administration Manual 06/29/2018
                                     Authorization to Release Health Information 10/7/2014
                                     Billing Recap (Retirees) 10/7/2014
                                     Continuation of Coverage Form 10/7/2014
                                     Member Appeal Request Form 02/15/2018
                                     Non AASIS Matching Form 10/7/2014
                                     Non-AASIS Notice of Termination & Retirement Form 10/7/2014
                                     Refund Request - State | Updated 08/31/2007 10/7/2014
                                     Request to Remove IT168-Life and IT377-Misc. Plans 02/5/2015
                        2017:  
                                     Minnesota Life Conversion Form 03/24/2017
                                     Minnesota Life Portability Form 03/24/2017
                        Manuals:  
                                     ARBenefits Task System Manual | Updated 02/13/11 11/28/2012
                                     Catapult Health 12/19/2017
                                     IRS/SSA/CMS Data Match Book 11/28/2012
                                     Minnesota Life Administration Manual 11/28/2012
                                     Minnesota Life FAQs 11/28/2012
                                     Minnesota Life Summer Continuation 06/14/2013
                                     State Health Insurance Representative Forms Routing Information Sheet 03/14/2017
                       2016:  
                       WageWork:  
                                     WageWorks ASE HIR FAQ 12/1/2015
Preferred Drug List:  
                          2017:  
                                     2017 PDL – Preferred Drug List 11/1/2017
Rates:  
                           2018:  
                                     2018 Plan Year | Active w/o Wellness Visit | Effective 01/01/2018 07/6/2017
                                     2018 Plan Year | Active w/Wellness Visit | Effective 01/01/2018 07/6/2017
                                     2018 Plan Year | Medicare Retiree | Effective 01/01/2018 07/6/2017
                                     2018 Plan Year | Non-Medicare Retiree | Effective 01/01/2018 07/6/2017
                          2017:  
                                     2017 Plan Year | Active w/o Wellness Visit | Effective 01/01/2017 08/16/2016
                                    2017 Plan Year | Active w/Wellness Visit | Effective 01/01/2017 08/16/2016
                                    2017 Plan Year | Medicare Retiree | Effective 01/01/2017 07/27/2016
                                    2017 Plan Year | Non-Medicare Retiree | Effective 01/01/2017 08/16/2016
                            
Schedule of Benefits:  
                           2017:  
                                     2017 ASE Schedule of Benefits - Basic 08/22/2017
                                     2017 ASE Schedule of Benefits - Classic 08/22/2017
                                     2017 ASE Schedule of Benefits - Premium 08/22/2017

DFA

ARBenefits is provided by the Employee Benefit Division of the Department of Finance & Administration

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ARBenefits
Employee Benefits Division
501 Woodlane St., Suite 500
Little Rock, AR 72201
(877) 815-1017 [Toll Free]
501-682-9656
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