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Arkansas State

Arkansas State | Public School

State Employees

 
Forms:  
     ARBenefits:  
             2020 Open Enrollment Guide 10/01/2019
             Affidavit of Spousal Health Care Coverage 10/5/2017
             ARBenefits RX Member Reimbursement Form 10/8/2014
             Authorization to Release Health Information 11/12/2019
             Enrolling Online With ARBenefits 8/15/2017
             Member Appeal Request Form 01/19/2018
             AR Benefits Primary Care Provider Form 04/27/2018
        2020:  
             ARBenefits:  
                         2020 Active State & Public School Change Form 11/05/2019
                         2020 Active State and School Enrollment Election Form  09/10/2019
              HSA/FSA  
                          Connect Your Care FSA Enrollment Form 11/18/2019
                          Connect Your Care HSA Enrollment Form 09/27/2019
                          CYC FSA Claim Form 09/23/2019
                          CYC HSA Claim Form 09/23/2019
                          CYC DCAP Claim Form 09/23/2019
             ARSEBA:  
                          2020 Dental Plan Comparison 09/10/2019
                          2020 Humana Vision Benefit Summary 09/10/2019
                          2020 Humana Vision Application 09/10/2019
             Colonial Life  
                          Colonial Life Enrollment Form 12/03/2019
                          Colonial Life ASE Rates 12/03/2019
                           ASE Basic and Enhanced Basic Coverage Brochure 12/03/2019
                           ASE Supplemental Coverage Brochure 12/03/2019
                           Colonial Life ASE Change Form 12/09/2019
   
       2019:  
             ARBenefits:  
                        2019 Active State & Public School Change Form 09/19/2018
                        2019 Active State and School Enrollment Election Form  08/27/2019
             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
                        CYC FSA Claim Form 01/14/2019
                        CYC HSA Claim Form 01/14/2019
                        CYC DCAP Claim Form 01/14/2019
                        HSA Change Form 04/15/2019
             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
   
Preferred Drug List:  
           2019:  
                    2019 PDL – Preferred Drug List 02/22/2019
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 Summary 11/3/2015
   
Schedule of Benefits:  
              2020:  
                      2020 ASE Schedule of Benefits - Basic  09/25/2019
                      2020 ASE Schedule of Benefits - Classic  09/25/2019
                       2020 ASE Schedule of Benefits - Premium 09/25/2019
              2019:  
                      2019 ASE Schedule of Benefits - Basic 05/08/2019
                      2019 ASE Schedule of Benefits - Classic 05/08/2019
                      2019 ASE Schedule of Benefits - Premium 05/08/2019
              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:  
                2019:  
                           2019 Table of Important Dates 01/04/2019
                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 07/10/2019
                         Retirement Health Enrollment Information & Instructions 03/21/2019
                         Retirement Packet 12/10/2019
                         Retiree Change Form 12/10/2019
                         2018:  
                            Securian:  
                             Minnesota Life Beneficiary Designation Form 01/04/2018
                             Minnesota Life Certificate of Coverage 01/04/2018
                             Minnesota Life Change Form 07/10/2019
                             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:  
                        2020:  
                                  2020 ASE Schedule of Benefits - Basic  09/25/2019
                                  2020 ASE Schedule of Benefits - Classic  09/25/2019
                                  2020 ASE Schedule of Benefits - Premium 09/25/2019
                                  2020 ASE Schedule of Benefits - Medicare Primary Retiree 09/25/2019
                       2019:  
                                  2019 ASE Schedule of Benefits - Basic 03/15/2019
                                  2019 ASE Schedule of Benefits - Classic 03/15/2019
                                  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 04/30/2019
                                     Authorization to Release Health Information 10/7/2014
                                     Billing Recap (Retirees) 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
   

DTSS

ARBenefits is provided by the Employee Benefits Division of the Department of Transformation & Shared Services

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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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