Employee Benefits

Public School

Arkansas State | Public School

School Employees 
Forms: 
     ARBenefits: 
           2021 PSE Open Enrollment Guide09/15/2020
          Affidavit of Spousal Health Care Coverage08/01/2020
          ARBenefits RX Member Reimbursement Form08/01/2020
          Authorization to Release Health Information08/01/2020
          Enrolling Online With ARBenefits09/15/2020
          Member Appeal Request Form02/04/2021
          ARBenefits Primary Care Provider Form01/04/2021
          Continuation of Insurance Due to Incapacity05/20/2021
    ARBenefits Election Forms 
          Active State and School Enrollment Election Form 04/27/2021
          Active State & Public School Change Form04/27/2021
          HSA/FSA 
               Connect Your Care HSA Enrollment Form09/27/2019
               Change in Status Form05/04/2020
  CYC Transfer of Assets Form12/03/2018
          Colonial Life 
               Colonial Life PSE Rates02/16/2021
               PSE Basic and Enhanced Basic Coverage Brochure12/03/2019
               PSE Supplemental Coverage Brochure12/03/2019
PSE Colonial Life Change Form04/07/2021
               Colonial Life Beneficiary Change Form12/20/2019
               Colonial Life Evidence of Insurability12/20/2019
  
Preferred Drug List: 
2021:
2021 PDL – Preferred Drug List05/13/2021
      2020: 
              2020 PDL – Preferred Drug List12/09/2020
     2019: 
              2019 PDL – Preferred Drug List02/22/2019
     Rates: 
            2018:
                  2018 Plan Year | Active w/o Wellness Visit | Effective 01/01/201807/6/2017
                  2018 Plan Year | Active w/Wellness Visit | Effective 01/01/201807/6/2017
                  2018 Plan Year | Cobra Rates | Effective 01/01/201807/6/2017
  
Schedule of Benefits: 
              2021 
                  2021 PSE Schedule of Benefits – Basic09/01/2020
                  2021 PSE Schedule of Benefits – Classic 09/01/2020
                  2021 PSE Schedule of Benefits – Premium 09/01/2020
              2020 
                  2020 PSE Schedule of Benefits – Basic09/25/2019
                  2020 PSE Schedule of Benefits – Classic 09/25/2019
                  2020 PSE Schedule of Benefits – Premium 05/08/2018
    2019 
             2019 PSE Schedule of Benefits – Basic05/08/2019
            2019 PSE Schedule of Benefits – Classic05/08/2019
           2019 PSE 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 – PSE Basic 201804/27/2018
                  Summary of Benefits and Coverage – PSE Classic 201804/27/2018
                  Summary of Benefits and Coverage – PSE Premium 201804/27/2018
            
School Retirees 
Forms: 
           ARBenefits: 
                Affidavit of Spousal Health Care Coverage06/07/2021
                Authorization to Release Health Information06/07/2021
                Bank Draft Authorization 06/07/2021
                Retiree Change of Address Form06/07/2021
                Retirement Health Enrollment Information & Instructions07/24/2020
               Retirement Packet06/11/2021
               Retiree Election Form06/07/2021
  
     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
              2021 Colonial Life Retiree Change Form04/07/2021
  
        2019: 
              Delta Dental:  
                   2018 Retiree Dental and Vision Brochure01/04/2018
  
Preferred Drug List: 
         Rates: 
         2018:
                   2018 Plan Year | Medicare Retiree | Effective 01/01/201807/6/2017
                   2018 Plan Year | Non-Medicare Retiree | Effective 01/01/201807/6/2017
  
Schedule of Benefits: 
           2020: 
                2020 PSE Schedule of Benefits – Basic09/25/2019
                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 Retiree09/25/2019
           2019: 
                   2019 PSE Schedule of Benefits – Basic03/15/2019
                   2019 PSE Schedule of Benefits – Classic03/15/2019
                   2019 PSE Schedule of Benefits – Premium12/05/2018
                   2019 PSE Schedule of Benefits – Medicare Primary Retiree12/05/2018
         2018: 
                    2018 PSE Schedule of Benefits – Basic9/20/2017
                    2018 PSE Schedule of Benefits – Classic01/25/2018
                    2018 PSE Schedule of Benefits – Medicare Primary Retiree02/09/2018
                    2018 PSE Schedule of Benefits – Premium01/25/2018
           
School Insurance Representatives 
Forms: 
             PSE Benefits Administration Manual04/28/2021
             PSE Summertime Portability Rules4/14/2021
             PSE Transfer Participation List05/04/2020
           ARBenefits:
               Affidavit of Spousal Health Care Coverage10/5/2017
               Authorization to Release Health Information10/7/2014
               FICA Savings Example12/22/2017
               Member Appeal Request Form01/19/2018
                Non AASIS Matching Form            10/7/2014
                Notice of PSE Transfer04/29/2021
                Notice of Termination and Retirement Form10/7/2014
1095C File Instructions2/18/2021
  
Preferred Drug List: 
           2018: 
                  2018 PDL – Preferred Drug List07/17/2018
           Rates: 
           2018: 
                  2018 Plan Year | Active w/o Wellness Visit | Effective 01/01/20187/6/2017
                  2018 Plan Year | Active w/Wellness Visit | Effective 01/01/20187/6/2017
                  2018 Plan Year | Medicare Retiree | Effective 01/01/20187/6/2017
                  2018 Plan Year | Non-Medicare Retiree | Effective 01/01/20187/6/2017
EXCELLENCE & EXPEDIENCE
PEOPLE OVER PROCESS

INNOVATION

CONTINUOUS IMPROVEMENT

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