Employee Benefits

Public School

Arkansas State | Public School

School Employees 
Forms: 
     ARBenefits: 
           2020 PSE Open Enrollment Guide10/07/2019
          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 ARBenefits08/15/2017
          Member Appeal Request Form01/19/2018
          Notice of Termination and Retirement Form10/7/2014
          AR Benefits Primary Care Provider Form01/23/2020
          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 09/25/2019
          HSA/FSA 
               Connect Your Care HSA Enrollment Form09/27/2019
               Change in Status Form05/04/2020
          Colonial Life 
               Colonial Life Enrollment Form12/03/2019
               Colonial Life PSE Rates12/03/2019
               PSE Basic and Enhanced Basic Coverage Brochure12/03/2019
               PSE Supplemental Coverage Brochure12/03/2019
               Colonial Life Beneficiary Change Form12/20/2019
               Colonial Life Evidence of Insurability12/20/2019
  
      2019: 
           ARBenefits: 
                2019 Active State & Public School Change Form09/19/2018
                2019 Active State and School Enrollment Election Form 08/27/2019
            HSA  
                Connect Your Care HSA Enrollment Form09/24/2018
                CYC Transfer of Assets Form12/03/2018
  
Preferred Drug List: 
      2020: 
              2020 PDL – Preferred Drug List03/02/2020
     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: 
              2020 
                  2020 PSE Schedule of Benefits – Basic09/25/2019
                  2020 PSE Schedule of Benefits – Classic 09/25/2019
                  2020 PSE Schedule of Benefits – Premium 09/27/2019
              2019 
                   2019 PSE Schedule of Benefits – Basic05/08/2019
                   2019 PSE Schedule of Benefits – Classic05/08/2019
                   2019 PSE Schedule of Benefits – Premium05/08/2018
             2018: 
                  2018 PSE Schedule of Benefits – Basic02/27/2018
                  2018 PSE Schedule of Benefits – Classic02/27/2018
                  2018 PSE Schedule of Benefits – Premium02/27/2018
  
Summary Plan Descriptions: 
            2018: 
                  2018 ARBenefits Summary Plan Description (effective 1/1/18)04/27/2018
                  Summary of Benefits and Coverage – PSE Basic 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 Coverage10/5/2017
                Authorization to Release Health Information10/7/2014
                Bank Draft Authorization | updated 02/13/202003/02/2020
                Retiree Change of Address Form06/06/2019
                Retirement Health Enrollment Information & Instructions03/30/2017
               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
  
        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 Manual02/28/2019
             PSE Summertime Portability Rules4/6/2017
             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 Transfer04/20/2020
                Notice of Termination and Retirement Form10/7/2014
  
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

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