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School Employees

 
Forms:  
     ARBenefits:  
          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 04/13/2016
          Enrolling Online With ARBenefits 08/15/2017
          Member Appeal Request Form 01/19/2018
          Notice of Termination and Retirement Form 10/7/2014
          2019 PSE Open Enrollment Guide 10/02/2018
          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   
                Connect Your Care HSA Enrollment Form 09/24/2018
                CYC Transfer of Assets Form 12/03/2018
           Securian:  
                Minnesota life Beneficiary Designation Form 09/21/2018
                Minnesota Life Certificate of Coverage 09/21/2018
                Minnesota Life Conversion Form 09/21/2018
                Minnesota Life Enrollment & Change Form 10/01/2018
                Minnesota Life Evidence of Insurability Form 09/21/2018
                Minnesota Life Portability Form 09/21/2018
   
     2018:  
          ARBenefits:  
               2018 Active State & Public School Change Form 08/09/2018
               2018 Active State and School Enrollment Election Form 08/24/2017
          HSA/FSA:  
               2018 DataPath HSA Election Form 03/12/2018
               DataPath HSA Claim Form 08/18/2017
               DataPath Transfer of Assets 08/18/2017
          Securian:  
               Minnesota Life - Beneficiary Designation and Change Request 08/24/2017
               Minnesota Life Certificate of Coverage 08/24/2017
               Minnesota Life Conversion Form 08/24/2017
               Minnesota Life Enrollment & Change Form 07/27/2018
               Minnesota Life Evidence of Insurability Form 08/24/2017
               Minnesota Life Portability Form 08/24/2017
     2017:  
         HSA/FSA:  
              DataPath Transition FAQ 12/7/2016
     2016:  
          HSA/FSA:  
             WageWorks PSE FAQ 12/3/2015
   
Preferred Drug List:  
     2018:  
              2018 PDL – Preferred Drug List 07/17/2018
     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
   
Schedule of Benefits:  
              2019  
                   2019 PSE Schedule of Benefits - Basic 09/24/2018
                   2019 PSE Schedule of Benefits - Classic 11/30/2018
                   2019 PSE Schedule of Benefits - Premium 09/24/2018
             2018:  
                  2018 PSE Schedule of Benefits - Basic 02/27/2018
                  2018 PSE Schedule of Benefits - Classic 02/27/2018
                  2018 PSE 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 - PSE Basic 2018 04/27/2018
                  Summary of Benefits and Coverage - PSE Classic 2018 04/27/2018
                  Summary of Benefits and Coverage - PSE Premium 2018 04/27/2018
             

School 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 and Change Request 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:  
         Rates:  
         2018:
                   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
   
Schedule of Benefits:  
           2019:  
                   2019 PSE Schedule of Benefits - Basic 12/05/2018
                   2019 PSE Schedule of Benefits - Classic 12/05/2018
                   2019 PSE Schedule of Benefits - Premium 12/05/2018
                   2019 PSE Schedule of Benefits - Medicare Primary Retiree 12/05/2018
         2018:  
                    2018 PSE Schedule of Benefits - Basic 9/20/2017
                    2018 PSE Schedule of Benefits - Classic 01/25/2018
                    2018 PSE Schedule of Benefits - Medicare Primary Retiree 02/09/2018
                    2018 PSE Schedule of Benefits - Premium 01/25/2018
            

School Insurance Representatives

 
Forms:  
             PSE Benefits Administration Manual 06/29/2018
             PSE Summertime Portability Rules 4/6/2017
             PSE Transfer Participation List 04/27/2018
           ARBenefits:
               Affidavit of Spousal Health Care Coverage 10/5/2017
               Authorization to Release Health Information 10/7/2014
               Continuation of Coverage Form 10/7/2014
               FICA Savings Example 12/22/2017
               Member Appeal Request Form 01/19/2018
                Non AASIS Matching Form             10/7/2014
                Notice of PSE Transfer 07/30/2018
                Notice of Termination and Retirement Form 10/7/2014
           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 6/14/2013
           2016:  
            WageWork:  
                 SOA HIR ER Site and Visual Aid Presentation 2/5/2016
                 WageWorks Employee Website Registration 7/7/2016
                 WageWorks Online Enrollment Training 7/7/2016
                 WageWorks PSE HIR FAQ 12/1/2015
   
Preferred Drug List:  
           2018:  
                  2018 PDL – Preferred Drug List 07/17/2018
           Rates:  
           2018:  
                  2018 Plan Year | Active w/o Wellness Visit | Effective 01/01/2018 7/6/2017
                  2018 Plan Year | Active w/Wellness Visit | Effective 01/01/2018 7/6/2017
                  2018 Plan Year | Medicare Retiree | Effective 01/01/2018 7/6/2017
                  2018 Plan Year | Non-Medicare Retiree | Effective 01/01/2018 7/6/2017
   
01/04/2018
01/04/2018
11/3/2015

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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