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School Employees

  
Forms:  
     ARBenefits:  
           2020 PSE Open Enrollment Guide 10/07/2019
          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 08/15/2017
          Member Appeal Request Form 01/19/2018
          Notice of Termination and Retirement Form 10/7/2014
          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  09/25/2019
          HSA/FSA  
               Connect Your Care HSA Enrollment Form 09/27/2019
          Colonial Life  
               Colonial Life Enrollment Form 12/03/2019
               Colonial Life PSE Rates 12/03/2019
               PSE Basic and Enhanced Basic Coverage Brochure 12/03/2019
               PSE Supplemental Coverage Brochure 12/03/2019
   
      2019:  
           ARBenefits:  
                2019 Active State & Public School Change Form 09/19/2018
                2019 Active State and School Enrollment Election Form  08/27/2019
            HSA   
                Connect Your Care HSA Enrollment Form 09/24/2018
                CYC Transfer of Assets Form 12/03/2018
   
     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:  
     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
   
Schedule of Benefits:  
              2020  
                  2020 PSE Schedule of Benefits - Basic 09/25/2019
                  2020 PSE Schedule of Benefits - Classic  09/25/2019
                  2020 PSE Schedule of Benefits - Premium  09/27/2019
              2019  
                   2019 PSE Schedule of Benefits - Basic 05/08/2019
                   2019 PSE Schedule of Benefits - Classic 05/08/2019
                   2019 PSE Schedule of Benefits - Premium 05/08/2018
             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 06/06/2019
                Retirement Health Enrollment Information & Instructions 03/30/2017
               Retirement Packet 12/10/2019
               Retiree Change Form 12/10/2019
        2019:  
             Securian:  
                    Minnesota Life - Beneficiary Designation and Change Request 06/20/2019
                    Minnesota Life 2019 Retiree Plan Summary 06/20/2019
                    Minnesota Life Retirement Deduction Authorization 06/20/2019
                    Minnesota Life Portability Form 06/20/2019
                    Minnesota Life Conversion 07/10/2019
                    Minnesota Life Retiree Change Form 07/10/2019
              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:  
           2020:  
                2020 PSE Schedule of Benefits - Basic 09/25/2019
                2020 PSE Schedule of Benefits - Classic  09/25/2019
                2020 PSE Schedule of Benefits - Premium  09/25/2019
                2020 PSE Schedule of Benefits - Medicare Primary Retiree 09/25/2019
           2019:  
                   2019 PSE Schedule of Benefits - Basic 03/15/2019
                   2019 PSE Schedule of Benefits - Classic 03/15/2019
                   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 02/28/2019
             PSE Summertime Portability Rules 4/6/2017
             PSE Transfer Participation List 06/14/2019
           ARBenefits:
               Affidavit of Spousal Health Care Coverage 10/5/2017
               Authorization to Release Health Information 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 04/25/2019
                Notice of Termination and Retirement Form 10/7/2014
   
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

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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