Employee Benefits
Employee Benefits

Arkansas State

Arkansas State | Public School

State Employees 
Forms: 
     ARBenefits: 
             2020 Open Enrollment Guide10/01/2019
             Affidavit of Spousal Health Care Coverage10/5/2017
             ARBenefits RX Member Reimbursement Form10/8/2014
             Authorization to Release Health Information11/12/2019
             Enrolling Online With ARBenefits8/15/2017
             Member Appeal Request Form01/19/2018
             AR Benefits Primary Care Provider Form01/21/2020
            Continuation of Insurance Due to Incapacity02/26/2020
        2020: 
             ARBenefits: 
                         2020 Active State & Public School Change Form11/05/2019
                         2020 Active State and School Enrollment Election Form 09/10/2019
              HSA/FSA 
                          Connect Your Care FSA Enrollment Form11/18/2019
                          Connect Your Care HSA Enrollment Form09/27/2019
                          CYC FSA Claim Form09/23/2019
                          CYC HSA Claim Form09/23/2019
                          CYC DCAP Claim Form09/23/2019
                          2020 HSA Change Form01/24/2020
                           Change in Status Form04/28/2020
             ARSEBA: 
                          2020 Dental Plan Comparison09/10/2019
                          2020 Delta Dental Enrollment Form12/16/2019
                          2020 Humana Vision Benefit Summary09/10/2019
                          2020 Humana Vision Application09/10/2019
             Colonial Life 
                     
                          Colonial Life ASE Rates12/03/2019
                           ASE Basic and Enhanced Basic Coverage Brochure12/03/2019
                           ASE Supplemental Coverage Brochure12/03/2019
                           Colonial Life ASE Change Form12/09/2019
                          Colonial Life Beneficiary Change Form12/20/2019
                          Colonial Life Evidence of Insurability12/20/2019
  
  
Preferred Drug List: 
           2020: 
                     2020 PDL – Preferred Drug List11/12/2020
           2019: 
                    2019 PDL – Preferred Drug List02/22/2019
Rates: 
  
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 – Premium09/25/2019
              2019: 
                      2019 ASE Schedule of Benefits – Basic05/08/2019
                      2019 ASE Schedule of Benefits – Classic05/08/2019
                      2019 ASE Schedule of Benefits – Premium05/08/2019
  
Summary Plan Descriptions: 
              2018: 
                        2018 ARBenefits Summary Plan Description (effective 1/1/18)04/27/2018
                        Summary of Benefits and Coverage – ASE Basic 201804/27/2018
                        Summary of Benefits and Coverage – ASE Classic 201804/27/2018
                        Summary of Benefits and Coverage – ASE Premium 201804/27/2018
  
Table of Important Dates: 
2021:
2021 Table of Important Dates10/12/2020
                2020: 
                            2020 Table of Important Dates12/12/2019
 
State Retirees 
Forms: 
               ARBenefits: 
                         Affidavit of Spousal Health Care Coverage10/5/2017
                         Authorization to Release Health Information10/7/2014
                         Bank Draft Authorization | updated 02/13/202003/02/2020
                         Retiree Change of Address Form07/10/2019
                         Retirement Health Enrollment Information & Instructions07/24/2020
                         Retirement Packet01/24/2020
                         Retiree Change Form12/10/2019
  
            Colonial Life Retiree Election Forms and Information 
                         2020 Colonial Life Retiree Enrollment Form      03/18/2020
                         2020 Colonial Life Retiree Rates & Information03/18/2020
                         2020 Colonial Life Retiree Beneficiary Change Form03/18/2020
                         2020 Colonial Life Retiree Change Form03/18/2020
  
Preferred Drug List: 
                       2020: 
                         2020 PDL – Preferred Drug List10/07/2020
Rates: 
                       2021: 
                               2021 Plan Year | Medicare Retiree | Effective 01/01/202108/26/2020
                               2021 Plan Year | Non-Medicare Retiree | Effective 01/01/202108/26/2020
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 – Premium09/25/2019
                                  2020 ASE Schedule of Benefits – Medicare Primary Retiree09/25/2019
                       2019: 
                                  2019 ASE Schedule of Benefits – Basic03/15/2019
                                  2019 ASE Schedule of Benefits – Classic03/15/2019
                                  2019 ASE Schedule of Benefits – Premium12/05/2018
                                  2019 ASE Schedule of Benefits – Medicare Primary Retiree12/05/2018
State Insurance Representatives 
Forms: 
                       AR Diamond Plan Opt-Out Form10/13/2016
                        ARBenefits: 
                                     Affidavit of Spousal Health Care Coverage10/5/2017
                                     ASE Benefits Administration Manual04/30/2019
                                     Authorization to Release Health Information10/7/2014
                                     Billing Recap (Retirees)10/7/2014
                                     Member Appeal Request Form02/15/2018
                                     Non AASIS Matching Form10/7/2014
                                     Non-AASIS Notice of Termination & Retirement Form10/7/2014
                                     Refund Request – State | Updated 08/31/200710/7/2014
                                     Request to Remove IT168-Life and IT377-Misc. Plans02/5/2015
EXCELLENCE & EXPEDIENCE
PEOPLE OVER PROCESS

INNOVATION

CONTINUOUS IMPROVEMENT

Scroll to Top