| State Employees | |
| Forms: | |
| ARBenefits: | |
| 2021 ASE Open Enrollment Guide | 01/27/2021 |
| 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 | 02/04/2021 |
| AR Benefits Primary Care Provider Form | 01/04/2021 |
| Continuation of Insurance Due to Incapacity | 02/26/2020 |
| | |
| ARBenefits: | |
| Active State & Public School Change Form | 04/27/2021 |
| Active State and School Enrollment Election Form | 04/27/2021 |
| 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 |
| 2020 HSA Change Form | 01/24/2020 |
| Change in Status Form | 01/14/2021 |
| ARSEBA: | |
| 2020 Dental Plan Comparison | 09/10/2019 |
| 2020 Delta Dental Enrollment Form | 12/16/2019 |
| 2020 Humana Vision Benefit Summary | 09/10/2019 |
| 2020 Humana Vision Application | 09/10/2019 |
| Colonial Life | |
| | |
| Colonial Life ASE Rates | 2/17/2021 |
| ASE Basic and Enhanced Basic Coverage Brochure | 12/03/2019 |
| ASE Supplemental Coverage Brochure | 12/03/2019 |
| Colonial Life ASE Change Form | 04/07/2021 |
| Colonial Life Beneficiary Change Form | 12/20/2019 |
| Colonial Life Evidence of Insurability | 12/20/2019 |
| | |
| | |
| Preferred Drug List: | |
| 2021: | |
| 2021 PDL – Preferred Drug List | 4/02/2021 |
| 2020: | |
| 2020 PDL – Preferred Drug List | 12/09/2020 |
| 2019: | |
| 2019 PDL – Preferred Drug List | 02/22/2019 |
| 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 – 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 |
| | |
| 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: | |
| 2021: | |
| 2021 Table of Important Dates | 10/12/2020 |
| 2020: | |
| 2020 Table of Important Dates | 12/12/2019 |
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