2024 ARBenefits State Retirement Packet

Employee Benefits Division · ARBenefits

PO Box 15610 · Little Rock, AR 72231 · 877-815-1017

Fax: 501-682-1200

Revised: 3.5.2024

Table of Contents

Eligibility................................................................

Non-Medicare Retirees.........................................

Medicare Retirees.................................................

Life, Dental, and Vision Insurance.........................

Completing the Retiree Election Form.................

MAPD Plan Summary of Benefits..........................

Primary Plan Schedule of Benefits........................

Rates......................................................................

Forms.....................................................................

Eligibility

Non-Medicare Retirees

Premium

Classic

Basic

Individual Deductible

$500

$2,500

$6,450

Family Deductible

$1,000

$3,200/$5,000

$12,900

Individual Out-of-Pocket

Medical: $3,000

Pharmacy: $3,100

$6,450

Family Out-of-Pocket

Medical: $6,000

Pharmacy: $6,200

$12,900

Doctor's Office Visit

$25 Copay

20% after Deductible

0% after Deductible

Specialist Office Visit

$50 Copay

20% after Deductible

0% after Deductible

Urgent Care Visit

$100 Copay

20% after Deductible

0% after Deductible

In-Patient Services

20% after Deductible

0% after Deductible

Out-Patient Services

20% after Deductible

0% after Deductible

Wellness Exams/Preventative

Care

If you are not yet eligible for Medicare, you can remain on ARBenefits health insurance.

You must notify your agency of your retirement from the state they can terminate your active

coverage. You can elect to continue working or become a dependent on your spouse’s

coverage. Once you lose that coverage you will have thirty (30) days to enroll on to an

ARBenefits plan.

To be eligible for ARBenefits retiree coverage:

Employees hired before July 2022 must be an active member of the ARBenefits plan on

the last day of their employment; OR

Employees hired after July 2022 must have five (5) cumulative years enrolled on the plan;

and

Begin drawing an annuity through their participating retirement system.3.

You have thirty (30) days to enroll in retiree coverage after meeting all three above criteria.

If you gain other group coverage upon retirement, you must enroll within thirty (30) days of

losing that coverage.

*Former employees are held to the retirement eligibility rules in place when they left employment.*

Pre-65 Non-Medicare Retiree Plan Options

Non-Medicare retirees can enroll in either the Premium, Classic, or Basic Plan. These are the

same plans as active members.

Revised: 3.5.2024

Medicare Retirees

Medicare eligible retirees can select from the two Medicare plans with ARBenefits starting the

first month of Medicare eligibility.

Ninety (90) days prior to turning sixty-five (65), you will receive a Pre-65 Election Request Letter.

You must submit your completed Retiree Election Form and all other required documentation to

EBD forty-five (45) calendar days from the date of the Election Request letter.

To enroll in Medicare Part A & Part B and learn more, you can:

Visit https://www.medicare.gov

Call 1-800-MEDICARE (1-800-633-4227)

You will need to provide EBD with a copy of your Medicare card showing the start date(s) of your

Medicare Part A & Part B.

Revised: 3.5.2024

The ARBenefits UHC MAPD plan differs from other Medicare plans you might see advertised

and is designed specifically for state and public school Medicare-eligible retirees. The

ARBenefits UHC MAPD plan includes the benefits of Medicare Part A, B, and D (you cannot

enroll in a separate Part D plan under this option).

Additional benefits include:

The ability to see any provider (in or out of network) as long as they accept Medicare

Free gym memberships

Enhanced hearing and vision benefits

Dental coverage

Drug coverage with drug list managed by UHC

For more information:

Call UnitedHealthcare: 1-844-488-3953

Visit:

www.transform.ar.gov/employee-benefits/retirees/medicare-advantage

Option 1 Provided by UnitedHealthcare

Medicare-eligible retirees can enroll in either the UnitedHealthcare (UHC) Group Medicare

Advantage with Prescription Drugs PPO Plan (MAPD) or the Health Advantage (HA) Medicare

Primary Plan.

Medicare Retiree Plan Options

IMPORTANT: You can only be enrolled in ONE (1) Medicare Advantage Plan or ONE (1)

Medicare Prescription Drug Plan (Medicare Part D) at a time. If you enroll in ANY other

Medicare Advantage or Medicare Part D plan, you will AUTOMATICALLY be disenrolled

from the ARBenefits UHC MAPD Group Plan and lose the benefits you have selected.

Option 2 Provided by Health Advantage

The Health Advantage Medicare Primary Plan coordinates with your Medicare Part A & B

benefits.

Arkansas State Employee Medicare retirees have prescription drug coverage under the Health

Advantage Plan and do not have to enroll in a separate Part D plan. The drug list for this plan is

managed by Navitus Health Solutions.

EBD will pay your physician claims like you have Medicare Part B coverage, even if you choose

not to participate in Part B.

For more information, contact EBD at 1-877-815-1017.

Remember: If you cancel your ARBenefits retirement coverage to leave the plan for any

reason OTHER than gaining employment with an Arkansas state agency or an Arkansas

public school district, that cancellation is FINAL and you cannot return to the ARBenefits

plan.

Coordination of Benefits with Medicare

The Health Advantage Medicare Primary Plan will coordinate as if Medicare Part A and Part B are

both in force at the time of service. If you do not have Medicare Part B, the Plan will pay as

though you have Medicare Part B, and you will be responsible for any incurred claims.

Revised: 3.5.2024

Medicare Part A (hospital insurance) does not

usually require recipients to pay a monthly

premium. Medicare Part A includes coverage

for:

Inpatient hospital stays

Hospice care

Skilled nursing facility care

Some home health care

Medicare Part B (physician insurance) is

optional and usually requires a monthly

premium. Medicare Part B includes coverage

for:

Certain doctor services

Outpatient care/Medical supplies

Preventative services

Examples of patient responsibility/liability with and without Medicare Part B:

Your payment with Medicare Part B

Office visit: $150

Medicare approved: $110

Medicare payment: $88

Medicare write-off: $40

ARBenefits payment: $22

Member amount due: $0

Your payment without Medicare Part B

Office visit: $150

Medicare approved: $110

Medicare payment: $0

Medicare write-off: $40

ARBenefits payment: $22

Member amount due: $88

Medicare Part C (Medicare Advantage) is another Medicare health plan choice that provides all

of your Part A and Part B coverage and many also provide Part D. Medicare pays a fixed

amount to companies offering Medicare Advantage Plans and they must follow the rules set by

Medicare.

Medicare Part D is a prescription drug plan that can be provided under a Part C plan or sold by

private insurance companies.

Part D coverage is included in the UHC MAPD plan and if you sign up for a Part D plan while on

the MAPD plan you will be kicked off and not permitted to return to any ARBenefits plan.

State retirees can sustain drug coverage through ARBenefits or a Part D plan if enrolled on the

Health Advantage Medicare Primary Plan. If you elect separate Part D coverage and have the

state’s pharmacy benefits, you will be responsible for any Part D repayment request from

ARBenefits.

Life Insurance

If you want to continue any Colonial Life coverage in retirement you must submit the Colonial

Life Election Form. If Colonial Life does not receive your election within thirty-one (31) days after

your retirement date, then you cannot regain that coverage later.

The Arkansas State Employee Benefit Advisors (ARSEBA) has more options for life insurance

coverage for retirees. Contact them to discuss those options at 501-224-5234.

Life, Dental, and Vision

Revised: 3.5.2024

Dental and Vision

Dental and vision are also provided through ARSEBA. For more information or to enroll, visit

www.mysmilecoverage.com/SOAR.

For retirees on the UHC MAPD Plan, dental and vision coverage includes an annual eye exam, a

$150 annual allowance for glasses or contacts (not related to cataract surgery), and limited

preventative dental care (review plan for allowances). UHC MAPD Plan members are allowed to

enroll in additional dental and vision coverage.

You are only allowed to change plans during the Retiree Open Enrollment Period. You are not

permitted to add any other dependents as part of Open Enrollment.

If you do not wish to make any changes to your plan during Open Enrollment, then no update

is needed from you.

Any changes made during Open Enrollment with take effect January 1 of the following year.

Retiree Open Enrollment

Eligible retirees can begin submitting the Retiree Election Form thirty (30) days prior to their

eligibility date and have until thirty (30) days AFTER the eligibility date to enroll in coverage.

You must submit a Retiree Election Form to EBD in order to be enrolled in retiree coverage.

These are the individual boxes you will see on the form and what EBD needs for each of them:

Event date: Your last day of employment.

Date annuity begins: When you start drawing your retirement check.

Action requested: Enroll in the plan.

Retirement system: Mark the correct retirement system. State employees mark APERS.

Benefit option: Choose which plan you wish to enroll.

If you or your covered spouse is Medicare eligible, you/your spouse can choose from the

UnitedHealthcare MAPD or the Health Advantage Primary Plan. Medicare eligibility is

determined by age - 65 or older - or by disability. Please include a copy of the Medicare

card as soon as possible.

If you and your covered spouse are NOT Medicare eligible, you can choose the Health

Advantage Premium, Classic, or Basic Plan.

Arkansas Law allows retirees a one-time option to enroll in the State and Public-School

Retirement Health Plan. Enrollment is either at the time of eligibility or delayed enrollment due

to current coverage on an employer-sponsored group health plan with a qualifying event of

involuntary loss of coverage. Once you leave the ARBenefits retirement plan, you will no

longer be eligible for participation in the plan. This decision is FINAL.

Coverage Level: Retiree only, Retiree and spouse, Retiree and child(ren), or Retiree and Family

Dependents: Only dependents on your active health plan can be added as dependents on your

retirement plan.

Sign and date your form and enter your email address.

Once eligibility requirements are met, the effective date of coverage is the first day of the

month following the date EBD receives your completed application for your retirement health

insurance.

Completing the Retiree Election Form

Revised: 3.5.2024

Once you become eligible for Medicare please provide EBD with a copy of your Medicare card,

indicating the start dates of both Medicare Part A and Part B coverage.

EBD may also request updated documents to maintain eligibility for our records.

Example: If EBD receives completed forms on 2/15, then coverage will begin on 3/1.

This packet contains additional forms that may require your attention, including:

Retiree Election Form: The general form that all retirees must complete to select coverage.

Authorization to Release Information: Allows authorization for another individual to access

your medical information. If you have a Power of Attorney (POA) on file, you do not need this

form.

ARBenefits Spousal Affidavit: This must be completed to add your spouse to the plan.

Colonial Life Retiree Deduction Authorization: If you want to continue with Colonial Life

coverage with the state, you must complete this form.

Dental and Vision Form: These must be completed to add retirement dental and/or vision

coverage.

Bank Draft Authorization Form: If your annuity is not enough to cover your premium or if you

would like your premiums drafted from your bank account, you will need to submit this form.

If you choose to have your premium drafted from your bank account, you must include a

second, voided check along with the Bank Draft Authorization Form.

Contact EBD with any additional questions

P.O. Box 15610

Little Rock, AR 72231

877-815-1017 [email protected]

Revised: 3.5.2024

Payment

EBD requires a check payment as the initial payment for retirement insurance.

If you choose to have your premiums taken from your annuity, it will begin the second month of

coverage.

You can choose to have premium payments come out of your bank account or your annuity at

any time.

Other Contact information

Phone: 501-682-7800

Toll Free: 800-682-7377

Website: www.apers.org

Phone: 501-224-5234

Fax: 501-663-1445

Toll Free: 800-682-7377

Email: [email protected]

Website: www.apers.org

Phone: 501-683-3151

Toll Free: 800-525-4368

Website: www.coloniallife.com

Phone: 501-301-9900

Website: www.voya.com

Phone: 800-633-4227

Website: www.Medicare.gov

Phone: 800-772-1213

Website: www.SSA.gov

Revised: 3.5.2024

Summary of Benefits

January 1, 2024 - December 31, 2024

This is a summary of what we cover and what you pay. Review the Evidence of Coverage (EOC) for

a complete list of covered services, limitations and exclusions. You can call Customer Service if

you want a copy of the EOC or need help. When you enroll in the plan, you will get more

information on how to view your plan details online.

ARBenefits Group Medicare Advantage (PPO)

Medical premium and limits

In-network and out-of-network

Monthly plan premium

Contact your group plan benefit administrator to

determine your actual premium amount, if applicable.

Maximum out-of-pocket amount

(does not include prescription drugs)

$0 for Medicare-covered services from any provider

If you reach the limit on out-of-pocket costs, you keep

getting covered hospital and medical services and

we will pay the full cost for the rest of the plan year.

Please note that you will still need to pay your

monthly premiums, if applicable, and cost-sharing for

your Part D prescription drugs.

Plan information

Medical benefits

In-network and out-of-network

Inpatient hospital care

$0 copay per stay

Our plan covers an unlimited number of days for an

inpatient hospital stay.

Outpatient

hospital

Cost sharing for

additional plan

covered services

will apply.

Ambulatory

surgical center

(ASC)

$0 copay

Outpatient

surgery

$0 copay

Outpatient

hospital services,

including

observation

$0 copay

Doctor visits

Primary care

provider

$0 copay

Virtual doctor

visits

$0 copay

Specialists

$0 copay

Preventive

services

Routine physical $0 copay; 1 per plan year*

Medicare-covered

$0 copay

· Abdominal aortic aneurysm

screening

· Alcohol misuse counseling

· Annual wellness visit

· Bone mass measurement

· Breast cancer screening

(mammogram)

· Cardiovascular disease

(behavioral therapy)

· Cardiovascular screening

· Cervical and vaginal cancer

screening

· Colorectal cancer screenings

(colonoscopy, fecal occult blood

test, flexible sigmoidoscopy)

· Depression screening

· Diabetes screenings and

monitoring

· Diabetes – Self-Management

training

· Dialysis training

· Glaucoma screening

· Hepatitis C screening

· HIV screening

· Kidney disease education

· Lung cancer with low dose

computed tomography (LDCT)

screening

· Medical nutrition therapy

services

Medical benefits

In-network and out-of-network

· Medicare Diabetes Prevention

Program (MDPP)

· Obesity screenings and

counseling

· Prostate cancer screenings

(PSA)

· Sexually transmitted infections

screenings and counseling

· Tobacco use cessation

counseling (counseling for

people with no sign of tobacco-

related disease)

· Vaccines, including those for the

flu, Hepatitis B, pneumonia, or

COVID-19

· “Welcome to Medicare”

preventive visit (one-time)

Any additional preventive services approved by Medicare during the

contract year will be covered.

This plan covers preventive care screenings and annual physical exams at

100%.

Emergency care

$0 copay (worldwide)

If you are admitted to the hospital within 24 hours,

you pay the inpatient hospital cost sharing instead of

the emergency care copay. See the “Inpatient

Hospital Care” section of this booklet for other costs.

Urgently needed services

$0 copay (worldwide)

If you are admitted to the hospital within 24 hours,

you pay the inpatient hospital cost sharing instead of

the urgently needed services copay. See the

“Inpatient Hospital Care” section of this booklet for

other costs.

Diagnostic tests,

lab and radiology

services, and X-

rays

Diagnostic

radiology services

(e.g. MRI, CT

scan)

$0 copay

Lab services

$0 copay

Diagnostic tests

and procedures

$0 copay

Therapeutic

radiology

$0 copay

Outpatient X-rays

$0 copay

Plan information

Medical benefits

In-network and out-of-network

Hearing services

Exam to diagnose

and treat hearing

and balance

issues

$0 copay

Routine hearing

exam

$0 copay, 1 exam per plan year*

Hearing Aids

The plan pays up to a $2,800 allowance for hearing

aids (combined for both ears) every 3 years.*

Routine dental

services

See Evidence of

Coverage for

more details.

Oral exams $0 copay, 2 procedures per plan year.

Routine cleaning $0 copay, 2 procedures per plan year.

Dental bitewing

X-rays

$0 copay, 1 procedure per plan year.

Minor Services

(Includes Fillings

and Nitrous

Oxide)

$0 copay, unlimited per plan year.

Benefit limit $0 yearly deductible and $500 combined in and out-

of-network plan year maximum.

If you receive services from an out-of-network dentist,

the plan pays according to a maximum allowable fee

schedule.

You pay all fees in excess of this amount.

Vision services

Exam to diagnose

and treat diseases

and conditions of

the eye

$0 copay

Eyewear after

cataract surgery

$0 copay

Routine eye exam

$0 copay, 1 exam every 12 months*

Routine eyewear

Plan pays up to $150 for eyeglasses, or $150 for

contact lenses instead of eyeglasses, every 12

months.*

Medical benefits

In-network and out-of-network

Mental

Health

Inpatient visit

$0 copay per stay

Our plan covers an unlimited number of days for an

inpatient hospital stay.

Outpatient group

therapy visit

$0 copay

Outpatient

individual therapy

visit

$0 copay

Virtual behavioral

visits

$0 copay

Skilled nursing facility (SNF)

$0 copay per day: days 1-100

Our plan covers up to 100 days in a SNF per benefit

period.

Outpatient Rehabilitation (physical,

occupational, or speech/language

therapy)

$0 copay

Ambulance

$0 copay

Medicare Part B

Drugs

Part B drugs may

be subject to Step

Therapy. See your

Evidence of

Coverage for

details.

Chemotherapy

drugs

$0 copay

Other Part B

drugs

$0 copay

Plan information

Prescription drugs

If the actual cost for a drug is less than the normal cost-sharing amount for that drug, you will pay

the actual cost, not the higher cost-sharing amount.

Your plan sponsor has chosen to make supplemental drug coverage available to you. This

coverage is in addition to your Part D prescription drug benefit. The drug copays in this section are

for drugs that are covered by both your Part D prescription drug benefit and your supplemental

drug coverage. You can view the Certificate of Coverage at retiree.uhc.com/ARBenefits or call

Customer Service to have a hard copy sent to you.

Your plan sponsor offers additional prescription drug coverage. Please see your Additional Drug

Coverage list for more information.

If you reside in a long-term care facility, you will pay the same for a 31-day supply as a 31-day

supply at a retail pharmacy.

Stage 1: Annual

Prescription (Part

D) Deductible

Since you have no deductible, this payment stage doesn’t apply.

Stage 2: Initial

Coverage

(After you pay your

deductible, if

applicable)

Retail Cost-Sharing Retail Cost-Sharing Mail Order Cost-

Sharing

31-day supply 93-day supply 93-day supply

Tier 1:

Preferred Generic

$15 copay $45 copay $30 copay

Tier 2:

Preferred Brand

$40 copay $120 copay $80 copay

Tier 3:

Non-Preferred

Drug

$80 copay $240 copay $160 copay

Tier 4:

Specialty Tier

$100 copay $300 copay $200 copay

Stage 3:

Coverage Gap

Stage

After your total drug costs reach $5,030, the plan continues to pay its share

of the cost of your drugs and you pay your share of the cost.

Stage 4:

Catastrophic

Coverage

During this payment stage, the plan pays the full cost for your covered

drugs. You pay nothing.

Pharmacy Out-of-Pocket Maximum

When your total Out-of-Pocket costs (what you pay) reach $3,100 you will not pay any copay or

coinsurance.

You will pay a maximum of $35 for a 1-month supply of each Part D insulin product covered by

our plan. Most adult Part D vaccines are covered at no cost to you.

Additional benefits

In-network and out-of-network

Acupuncture

services

Medicare-covered

acupuncture

(for chronic low

back pain)

$0 copay

Routine

acupuncture

services

$0 copay, up to 12 visits per plan year*

Chiropractic

services

Medicare-covered

chiropractic care

(manual

manipulation of

the spine to

correct

subluxation)

$0 copay

Routine

chiropractic

services

$0 copay, up to 15 visits per plan year*

Diabetes

management

Diabetes

monitoring

supplies

$0 copay

We only cover Accu-Chek® and OneTouch® brands.

Covered glucose monitors include: OneTouch Verio

Flex®, OneTouch Verio Reflect®, OneTouch® Verio,

OneTouch® Ultra 2, Accu-Chek® Guide Me, and

Accu-Chek® Guide.

Test strips: OneTouch Verio®, OneTouch Ultra®,

Accu-Chek® Guide, Accu-Chek® Aviva Plus, and

Accu-Chek® SmartView.

Other brands are not covered by your plan.

Medicare covered

Continuous

Glucose Monitors

(CGMs) and

supplies

$0 copay

Diabetes self-

management

training

$0 copay

Plan information

Additional benefits

In-network and out-of-network

Therapeutic

shoes or inserts

$0 copay

Durable Medical

Equipment

(DME) and

Related Supplies

Durable Medical

Equipment (e.g.,

wheelchairs,

oxygen)

$0 copay

Prosthetics (e.g.,

braces, artificial

limbs)

$0 copay

Fitness program

Renew Active® by UnitedHealthcare

$0 copay for Renew Active® by UnitedHealthcare, the

gold standard in Medicare fitness programs for body

and mind. It includes a free gym membership at a

fitness location you select from our nationwide

network, online classes, content about brain health

and fun social activities. Visit UHCRenewActive.com

to learn more today.

Once you become a member you will need a

confirmation code. Log in to your plan website, go to

Health & Wellness and select Renew Active or call the

number on your UnitedHealthcare member ID card to

obtain your code.

Foot care

(podiatry

services)

Foot exams and

treatment

$0 copay

Routine foot care $0 copay, 6 visits per plan year*

Over-the-counter (OTC) card

Healthy Benefits Plus

$0 copay

$40 credit each quarter to purchase approved OTC

items from network retail locations or through the

OTC catalog. Credits expire at the end of each

quarter. Shop in store, call or go online.

1-833-216-6709, TTY 711, visit

HealthyBenefitsPlus.com/UHCRetiree, or download

the Healthy Benefits Plus app.

Additional benefits

In-network and out-of-network

UnitedHealthcare

Healthy at Home

$0 copay for the following benefits for up to 30 days

after each inpatient and SNF discharge:

· 28 home-delivered meals*

· 12 one-way trips to medically related

appointments and the pharmacy*

· 6 hours of non-medical personal care services - a

professional caregiver can help with preparing

meals, companionship, medication reminders,

and more. No referral required.

Call the customer service number on your

UnitedHealthcare member ID card for more

information and to use your benefits.

*Call Customer Service to request a referral for each

discharge.

Some restrictions and limitations may apply.

Home health care

$0 copay

Hospice

You pay nothing for hospice care from any Medicare-

approved hospice. You may have to pay part of the

costs for drugs and respite care. Hospice is covered

by Original Medicare, outside of our plan.

Personal emergency response

system (PERS)

Lifeline

$0 copay for a personal emergency response system.

Help is only a button press away. A PERS wearable

device can quickly connect you to the help you need,

24 hours a day in any situation. Call or go online to

order your device. 1-855-595-8485, TTY 711 or

lifeline.com/uhcgroup

24/7 Nurse Support

Receive access to nurse consultations and additional

clinical resources at no additional cost.

Opioid treatment program services

$0 copay

Outpatient

substance abuse

Outpatient group

therapy visit

$0 copay

Outpatient

individual therapy

visit

$0 copay

Plan information

Additional benefits

In-network and out-of-network

Rally Coach™ Programs

$0 copay for Rally Coach™ programs: Real Appeal®

Weight Management, Real Appeal Diabetes

Prevention, Wellness Coaching and a tobacco

cessation program.

Call or go online to get started today.

rallyhealth.com/retiree

•Real Appeal 1-844-924-7325, TTY 711

•Rally Wellness Coaching 1-800-478-1057, TTY 711

•Tobacco Cessation 1-866-784-8454, TTY 711

*Refer to your Evidence of Coverage for eligibility

requirements

Renal Dialysis

$0 copay

Some of the network benefits listed may require your provider to obtain prior authorization. You never need approval

in advance for plan covered services from out-of-network providers. Please refer to the Evidence of Coverage for a

complete list of services that may require prior authorization.

Authorization is required for non-emergency Medicare-covered ambulance air transportation. Authorization is not

required for non-emergency Medicare-covered ambulance ground transportation. Emergency ambulance (ground or

air) does not require authorization.

*Benefits are combined in and out-of-network

About this plan

ARBenefits Group Medicare Advantage (PPO) is a Medicare Advantage PPO plan with a Medicare

contract.

To join this plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, live in our

service area as listed below, be a United States citizen or lawfully present in the United States, and

meet the eligibility requirements of your former employer, union group or trust administrator (plan

sponsor).

Our service area includes the 50 United States, the District of Columbia and all US territories.

About providers and network pharmacies

ARBenefits Group Medicare Advantage (PPO) has a network of doctors, hospitals, pharmacies and

other providers. You can see any provider (network or out-of-network) at the same cost share, as

long as they accept the plan and have not opted out of or been excluded or precluded from the

Medicare Program. If you use pharmacies that are not in our network, the plan may not pay for

those drugs, or you may pay more than you pay at a network pharmacy.

You can go to retiree.uhc.com/ARBenefits to search for a network provider or pharmacy using

the online directories. You can also view the plan Drug List (Formulary) to see what drugs are

covered and if there are any restrictions.

Plan information

What does ARBenefits cover for Medicare Primary Retirees?

Medicare Does Not Pay

ARBenefits Retiree Plan Covers

Part A Hospital Services

Inpatient hospital deductible each benefit

period

ARBenefits pays the deductible

Copayment per day for days 61-90 in a hospital

ARBenefits pays the copayment per day

Copayment per day for days

91-150 (Lifetime Reserve)

ARBenefits pays the copayment per day

100% of Medicare - Allowable expenses

for additional 365 days after Medicare

hospital benefits stop completely

ARBenefits pays

Calendar year blood deductible (First 3 Pints

of Blood) If deductible is not met by the

replacement of blood

ARBenefits pays

Copayment per day for days 21-100 in a

Skilled Nursing Facility

ARBenefits pays the copayment per day

Part B Physician and Medical Services

Part B deductible ARBenefits pays the deductible

Normally 20% of Medicare-approved

amount (Part B Coinsurance) and 20% of

Medicare-approved charges for Durable

Medical Equipment (After Part B Deductible

Is Met)

ARBenefits pays 20% of the Medicare-approved

amount

Medicare Part B excess charges 100%

(This benefit would apply when you receive

services from a physician that does not

accept Medicare assignment.)

Coverage will be determined based on the level

of coverage outlined in the SPD for active and

non- Medicare members. Services paid at 100%

will be no charge. Plan will pay 80% for Medicare

Part B excess charges not paid by Medicare, but

will be paid according to the deductible, copay

and coinsurance when applicable.

2024 Plan Year - Schedule of Benefits

Rev: 10/12/2020

Coordination of Benefits with Medicare

• The ARBenefits Medicare Premium Plan for Retirees will coordinate as if Medicare Part A and

Part B are both in force at the time of service. If the member does not have Medicare Part B,

the Plan will pay as though the member does have Part B and the member will have full

financial responsibility for incurred claims.

• The Plan will cover services for our Medicare Primary members as for our active and non-

Medicare members. If Medicare does not cover a particular vaccine/service/etc., the plan will

cover the service at the Premium plan level if coverage is provided for our active

and non-

Medicare members.

• Coverage will be determined based on the level of coverage outlined in the SPD for active

and non-Medicare members - services paid at 100% will be no-charge. For all other services

deductible, copay and coinsurance will apply when applicable.

• All physician, hospital, and medical services offered to Medicare Primary Retirees on the

ARBenefits Plan are subject to the provisions of the Schedule of Benefits listed in the

Summary Plan Description. The ARBenefits Plan does not allow all services allowed by

Medicare. Please review the SPD carefully to determine if a service is covered.

Prescription Drug Benefit for Medicare Primary Retirees

State Retiree

• Members have the option of sustaining drug

coverage through ARBenefits or Medicare Part D.

RATES

ARKANSAS STATE NON-MEDICARE RETIREE

MONTHLY PREMIUMS

RATES EFFECTIVE JANUARY 1, 2024 – DECEMBER 31, 2024

PLAN

BASE MONTHLY

PREMIUM

STATE & PLAN

CONTRIBUTION

TOTALLY MONTHLY

RETIREE COST

PREMIUM

RETIREE ONLY $1,014.13 $683.07 $331.06

RETIREE & NON-MEDICARE SPOUSE $2,028.26 $1,166.50

$861.76

RETIREE & CHILD(REN) $1,391.61 $784.37

$607.24

RETIREE & NON-MEDICARE SPOUSE &

CHILD(REN)

$2,405.74 $1,311.88 $1,093.86

RETIREE & MEDICARE PRIMARY SPOUSE $1,534.29 $867.95 $666.34

RETIREE & MEDICARE PRIMARY SPOUSE &

CHILD(REN)

$1,911.77 $969.25 $942.52

RETIREE & MAPD PRIMARY SPOUSE $1,184.44 $836.06 $348.38

RETIREE & MAPD PRIMARY SPOUSE &

CHILD(REN)

$1,561.92 $937.36

$624.56

CLASSIC

RETIREE ONLY $881.66 $655.18 $226.48

RETIREE & SPOUSE $1,763.31 $1,124.63 $638.68

RETIREE & CHILD(REN) $1,209.83 $760.79

$449.04

RETIREE & FAMILY $2,091.49 $1,274.35 $817.14

BASIC

RETIREE ONLY $778.15 $634.07 $144.08

RETIREE & SPOUSE $1,556.30 $1,094.96 $461.34

RETIREE & CHILD(REN) $1,067.79 $744.33 $323.46

RETIREE & FAMILY $1,845.94 $1,249.30 $596.64

The Basic Plan meets the minimum essential coverage required under A.C.A.

State Con

tribution is funded by legislation.

Plan Contribution is funded by ASE Trust Fund as Claims Reserve Allocation.

ARKANSAS STATE MEDICARE UNITEDHEALTHCARE (UHC) MAPD GROUP

RETIREE MONTHLY PREMIUMS (MEDICAL & PHARMACY)

RATES EFFECTIVE JANUARY 1, 2024 – DECEMBER 31, 2024

MEDICARE ELIGIBLE

BASE MONTHLY

PREMIUM

STATE & PLAN

CONTRIBUTION

TOTAL MONTHLY

RETIREE COST

MAPD RETIREE ONLY $170.31 $153.28 $17.03

MAPD RETIREE & NON-

MEDICARE SPOUSE

$1,184.44 $636.42 $548.02

MAPD RETIREE &

CHILD(REN)

$547.79 $254.27 $293.52

MAPD RETIREE & MAPD

CHILD

$340.62 $305.56 $34.06

MAPD RETIREE & NON-

MEDICARE SPOUSE &

CHILD(REN)

$1,561.92 $781.78 $780.14

MAPD RETIREE & NON-

MEDICARE SPOUSE &

MAPD CHILD

$1,354.75 $789.70 $565.05

MAPD RETIRE & MAPD

SPOUSE

$340.62 $306.56 $34.06

MAPD RETIREE & MAPD

SPOUSE & CHILD(REN)

$718.10 $407.26 $310.84

MAPD RETIREE & MAPD

SPOUSE & MAPD CHILD

$510.93 $459.84 $51.09

State Contribution is funded by legislation.

Plan Contribution is funded by the ASE Trust Fund as Claims Reserve Allocation.

ARKANSAS STATE MEDICARE HEALTH ADVANTAGE (HA)

PREMIUM RETIREE MONTHLY PREMIUMS

RATES EFFECTIVE JANUARY 1, 2024 – DECEMBER 2024

MEDICARE ELIGIBLE BASE MONTHLY PREMIUM

STATE & PLAN

CONTRIBUTION

TOTALLY MONTHLY

RETIREE COST

RETIREE ONLY $520.16 $287.12 $233.04

RETIREE & NON-MEDICARE SPOUSE $1,534.29 $741.79 $792.50

RETIREE & CHILD(REN) $897.64 $368.72 $528.92

RETIREE & NON-MEDICARE SPOUSE &

CHILD(REN)

$1,911.77 $876.55 $1,035.22

RETIREE & MEDICARE PRIMARY

SPOUSE

$1,040.32 $482.04 $558.28

RETIREE & MEDICARE PRIMARY

SPOUSE & CHILD(REN)

$1,421.51 $567.33 $854.18

State Contribution is funded by legislation.

Plan Contribution is funded by ASE Trust Fund as Claims Reserve Allocation.

FORMS

State & Public-School

Retirement Election Form

Employee Information

First Name MI Date of Birth Gender

Event

Last Name

Home/Cell NumberEvent Date

Mailing Address

City

State

Zip Code

Enroll in the Plan

Add/Drop Dependents

Enroll as a Surviving Spouse

Type of Action

Cancel Coverage

Open Enrollment

Choose Retirement System

APERS (State) 998

APERS (School) 059002

APERS Judicial 021

Highway Dept. 091

ATRS (State) 999

ATRS (School) 059001

Please check the correct column to ADD a dependent to the plan or DROP a dependent currently covered. Proof of a

dependent’s eligibility must be submitted with this application for all dependents. To complete the RELATIONSHIP column, use

the number that describes the dependent(s). Spouse - 1, Child - 2, Permanent Legal Guardian - 3

Employee Signature Date

Email Address

I authorize deductions of the required contributions (if applicable). I understand that my elections can only be changed during the next open

enrollment period or if I have a qualifying event as deﬁned in the ARBeneﬁts Summary Plan Description. I understand I must request such changes

within 30 days of the qualifying event. On behalf of myself and anyone enrolled on or added to this form, I authorize any health care professional

or entity to give the health plan/insurer or any of their designees, any and all records or information pertaining to medical history or services ren-

dered to the heath plan/insurer, for any administrative purpose, including evaluation of an application or claim. I also authorize on behalf of health

plan/insurer the use of a Social Security Number for the purpose of identiﬁcation. A photocopy of this authorization will be as valid as the original.

Please note that falsifying documents, misrepresenting dependent status or using other fraudulent actions to gain coverage may be criminal acts

and can lead to permanent termination of coverage. I understand by signing the election form, it means I have read and agree with the attached

instruction page and understand the options I chose on the election form.

Coverage

Add/Drop Dependents

Subscriber Certiﬁcation

SUBMISSION TO EBD IS FINAL

Department of Transformation and Shared Services • Employee Beneﬁts Division

P.O. Box 15610 • Little Rock, AR 72231-5610 • Fax: 501-682-1200

Rev. 8/1/2023

Social Security Number

Date Annuity Begins

VALIC/TIFF - Alternate Retirement

(Bank Draft)

Premium

Classic

Basic

Choose

Coverage

Level

Employee Only

Employee & Spouse

Employee & Child(ren)

Employee & Family

Medicare

Our plans require Medicare-eligible Retirees to be enrolled in BOTH Medicare Part A & B.

United HealthCare MAPD

Health Advantage Premium

Pre-65 Plan

Post-65 Plan

Annuity

Checking*

Savings*

Physical Address

Payment Method

*Please complete Bank Draft

Authorization Form

ADD DROP

NAME (FIRST, MI, LAST)

MALE

FEMALE

SOCIAL SECURITY NUMBER

RELATIONSHIP

DATE OF BIRTH

Instructions

ALL PORTIONS OF THE ELECTION FORM MUST BE COMPLETED OR IT WILL BE SENT

BACK FOR COMPLETION PRIOR TO PROCESSING.

Currently UnitedHealthCare is the provider for the Group Medicare Advantage Plan (MAPD) plan and Health Advantage is the

provider for the Medicare Primary Premium Plan. Each Medicare eligible member is required to maintain Medicare Part A & B

coverage. A copy of the Medicare card is required for any subscriber and/or spouse/dependent.

ARBeneﬁts Medicare Primary Premium Plan for retirees will coordinate as if Medicare Part A & B are both in force at the time of

service. If the member does not have Part B, the plan will pay as though the member does have Part B coverage. The member

will have full ﬁnancial responsibility for incurred claims.

Public School Retirees who choose the Medicare Primary Premium Plan will NOT have pharmacy beneﬁts through this plan. You

will be required to obtain Medicare Part D for your pharmacy needs.

If you choose the UnitedHealthCare MAPD Plan and enroll in a separate Medicare plan outside of ARBeneﬁts, you will

automatically be canceled from ARBeneﬁts coverage. If you have questions about your coverage, call ARBeneﬁts before making

your decision.

The Bank Draft Authorization Form, with VOIDED check attached, is required if your retirement annuity is not able to cover the

full cost of your premiums. WE CANNOT PROCESS WITHOUT A VOIDED CHECK.

Your premiums are taken out post-tax.

IF YOU CANCEL YOUR RETIREMENT INSURANCE OTHER THAN BY GAINING EMPLOYMENT WITH A STATE AGENCY OR

PUBLIC SCHOOL, YOU WILL NOT BE ABLE TO COME BACK TO THE PLAN AND THE DECISION IS FINAL.

Completion of this form does not guarantee coverage on the retirement plan as certain conditions must be met in order to be

enrolled on to either ARBeneﬁts Retirement Plans.

RECIPROCITY SERVICE

• A retiree who is fully vested as a state employee AND fully vested as a public school employee (a participating member

under both APERS and ATRS and drawing a retirement annuity from each may choose to enroll in with the ASE or PSE

retirement health plan.

• A retiree who is not fully vested under either system, but has enough time between the two systems to be eligible for

reciprocity service will be enrolled in the retiree health plan of the system with the most service.

VESTING

• State and Public School retirees changed from a ten (10) year vesting to a ﬁve (5) year vesting period effective 7/1/1997.

• Retirees with service prior to 7/1/1997 are still held to the ten (10) year vesting period.

• Non-teaching school retirees that are paid under Arkansas Public Employees Retirement System (APERS) have school rates.

• Most college and county employed retirees are NOT eligible under the State & Public School Retirement Health Insurance.

Reciprocity services from these agencies do not make a retiree eligible for the health insurance.

Proof of dependent eligibility is required. Examples of required documentation: birth certiﬁcates, marriage licenses, court

documents, and a Certiﬁcate of Credible Coverage (COCC) for loss of coverage.

If adding dependent as a permanent legal guardian you must include court documents and they will be subject to annual review.

You can also submit documents online through the ARBeneﬁts Member Portal at www.myarbeneﬁts.org.

For assistance, contact ARBeneﬁts at 1-877-815-1017 Monday - Friday, from 8:00AM - 4:30PM CST or email us at

[email protected].

Learn more about plans, costs, and network providers at www.transform.ar.gov/employee-beneﬁts/retirees/

Rev. 8/1/2023

MAIL OR FAX FORM AND ACCOMPANYING DOCUMENTS TO:

Department of Transformation and Shared Services - Employee Beneﬁts Division

PO Box 15610, Little Rock, AR 72231-5610 - FAX: 501-682-1200

Coverage is effective the 1st of the month and termed at the end of the month following date of receipt and

based on eligibility rules.

SUBMISSION TO EBD IS FINAL

Afﬁdavit of Spousal

Healthcare Coverage

Employee Name

Employee SSN

Spouse Name

Spouse SSN

To be completed by employee electing to enroll a spouse or when dropping a spouse due to

gaining employer group coverage.

Pursuant to Arkansas Code Ann. §21-5-407(4), any spouse who is offered coverage for Medical Beneﬁts

under any other employer-sponsored health plan is NOT eligible to be covered under the ARBeneﬁts Plan.

1. Is your spouse currently employed?

Yes (If yes, please proceed to question #2)

No (If no, sign and return this form along with your election form and a copy

of your marriage license)

2. Is your spouse currently employed by an Arkansas state agency or

public school district?

Yes (If yes, sign and return this form along with your election form and a copy

of your marriage license)

No (If no, proceed to question #3)

3. Is your spouse eligible for his/her employer-sponsored group

health plan?

Yes

No (If no, please submit information from your spouse’s employer as to why

your spouse is not covered)

By signing this afﬁdavit I certify that the information provided above is accurate. I understand that any

misrepresentations in the information I provided above will permit the ARBeneﬁts Plan to terminate my coverage. If

applicable, I authorize the release of the information noted above and agree to its use in the application process for

ARBeneﬁts Plan coverage.

Employee signature:

Spouse signature:

Date:

Rev. 8/1/2023

For any questions or concerns, contact EBD at 1-877-815-1017 or email

[email protected]

MAIL OR FAX FORM AND ACCOMPANYING DOCUMENTS TO:

Department of Transformation and Shared Services - Employee Beneﬁts Division

PO Box 15610, Little Rock, AR 72231-5610 - FAX: 501-683-0983

BANK DRAFT

AUTHORIZATION

I hereby authorize the Department of Transformation and Shared Services - Employee

Beneﬁts Division to initiate debit entries and to initiate, if necessary, credit entries and

adjustments for any debits in error to our bank account indicated at the ﬁnancial institution

named below (VOIDED CHECK), hereinafter called Depository, to debit and/or credit the same

such account. First month Retirement and COBRA payments MUST BE MADE BY CHECK.

All COBRA NSF drafts must be paid by the end of the month to avoid termination of coverage.

Select One:

Retirement Effective Date:

COBRA Effective Date:

Type of Account Date of Draft

Checking (requires

voided check)

Savings

5th

7th

15th

20th

28th

*Not available for COBRA

Routing #:

Account #:

This authorization shall remain in effect unless the Employee Beneﬁts Division has received written notiﬁcation

from me (us) of its termination in such time and in such manner as to afford the Employee Beneﬁts Division

and Depository a reasonable opportunity to act on it.

Authorized Signer on Account:

Authorized Signer Signature:

(Please print name clearly)

(Authorized Signer) (Date)

Member ID #:

Per Arkansas Code Ann. §5-37-301, a $25.00 Return Item Charge fee plus a $2.00 service fee

for bank drafts will be assessed per item returned not paid by the bank.

*** Please enclose the ﬁrst month’s payment AND a voided check for bank drafts. MUST have original check -

no copies (Deposit Slip can NOT be used) ***

Rev. 8/1/2023

Annuity

Bank Draft

MAIL FORM AND ACCOMPANYING DOCUMENTS TO:

Department of Transformation and Shared Services - Employee Benefits Division

PO Box 15610, Little Rock, AR 72231-5610

Last 4 SSN:

Authorization to Release

Information

This form is used to release your protected health infomation as required by federal and state privacy laws. Your authorization allows

the Employee Beneﬁts Division (EBD) to release your protected health information to a person or organization that you choose. You

can revoke this authorization at any time by submitting a request in writing to EBD or ﬁlling out the Authorization to Revoke Release of

Health Information form. Revoking this authorization will not effect any action taken prior to receipt of your written request.

Member Information (individual whose information will be released)

Name: Member ID #:

Address:

City:

State: Zip:

Home Number: Cell Number: Birth date:

I authorize EBD to release my protected health information as described below

Person’s Name or Organization:

Address: Home Number:

Person’s Name or Organization:

Address: Home Number:

Recipient (Person or Organization that will receive your information)

Description of the Information to be Released

Entire Health Record

Other, please describe

This authorization will expire (Check ONLY ONE Box)

When I revoke this authorization

Upon the following date, event, or condition

If I fail to select an option above, this authorization will expire in twelve (12) months from the date of this signing.

I understand that this authorization to release information is voluntary and is not a condition of enrollment in the ARBeneﬁts Health Plan, eligibility for

beneﬁts, or payment of claims. I also understnad that once the information is disclosed pursuant to this authorization, it may be disclosed by the recipient

and the information may not be protected by federal privacy regulations. I understand that the information in my health record may include information

relating to sexually transmitted diseases, behavioral or mental health services, and treatment fo alcohol and drug abuse.

By signing below, I authorize the release of my protected health information as described above.

Date

Printed Name of Member or Legal Representative

Signature of Member or Legal Representative

Rev. 8/1/2023

MAIL OR FAX FORM AND ACCOMPANYING DOCUMENTS TO:

Department of Transformation and Shared Services - Employee Benefits Division

ATTN:

Eligibility Department - PO Box 15610, Little Rock, AR 72231-5610 - FAX: 501-683-0983

ARALAKAZCACOCTDEFLGAHIIDILINIAKSKYLAMEMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVEVAWAWVWIWY

RETIREE CHANGE OF

ADDRESS FORM

First Name MI Last Name

Member ID or Social Security Number

Address

State Zip CodeCity

PREVIOUS ADDRESS

NEW ADDRESS

Signature

Address

State Zip CodeCity

Date Phone Number

MAIL COMPLETED FORM TO:

TSS - EMPLOYEE BENEFITS DIVISION

PO BOX 15610

LITTLE ROCK, AR 72231

FAX COMPLETED FORM TO:

501-682-1200

Rev. 8/1/2023

Changing Physical Address Changing Mailing Address Changing Both

ARALAKAZCACOCTDEFLGAHIIDILINIAKSKYLAMEMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVEVAWAWVWIWY

Insurance pr

oducts are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.

Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

3-21 | NS-586158

State of Arkansas Retirees

Employees who retire after January 1, 2020 may continue their Colonial Life Group Term Life with AD&D

coverage(s). Retirees may elect to take up to 50% of their current active employee coverage into retirement.

Colonial Life Group Term Life with AD&D coverage(s) are subject to an additional 50% benefit reduction at

age 75 for retiree and spousal coverage(s). Increases in coverage are not allowed at or after retirement.

Please complete the Colonial Life Service and Payment Authorization Form and return it within 31 days of

your retirement.

n Forms received aer 31 days will not be processed.

n Completed forms may be returned by mail or fax:

Colonial Life

PO BOX 1365

Columbia, SC 29202

Fax #: 803-678-6861

The dedicated Arkansas Customer Service number is 1-855-868-6009

Monday – Friday – 8:00 a.m. – 8:00 p.m.

Please remember that your active coverage must be canceled by your employer before your retirement

elections can be processed.

n Please also note that you may receive a termination notice for your active employee coverage

prior to your retirement coverage(s) being issued.

Supplemental Group Term Life with AD&D coverage is an age banded product which means that your

rates will increase in January after you cross into a new age band.

Additional questions may be answered by reviewing the Colonial Life Group Term Life with AD&D

Insurance for Retired Employees brochure.

Note: If you do not want to continue your Colonial Life Group Term Life with AD&D coverage(s) into

retirement, you don’t need to complete a Colonial Life Service and Payment Authorization Form. Your

active employee coverage will automatically terminate aer your retirement date.

Last Revision 4.13.20 SOA RETIREE SERVICE

83364

Page 1 of 2

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY, PO BOX 1365, COLUMBIA, SC 29202

STATE OF ARKANSAS RETIREES - GROUP TERM LIFE WITH AD&D SERVICE FORM AND PAYMENT AUTHORIZATION FORM

Retired:  AR State Employee  AR Public School Employee Retirement Date (mm/dd/yyyy):

Name of District/Agency retired from: Code of District/Agency retired from:

Retiree Information

Retiree

Name (First, MI, Last)

Gender



Birthdate (mm/dd/yyyy)

Social Security No.

Home Address – Street City State Zip Code Member No.

Email Address

Primary Phone No.

Secondary Phone No.

List all policies/certificate numbers related to this request (Required to process):

Qualifying Life Event



Marriage



Legal Separation



Birth or Adoption of Child



Death of Spouse

 Divorce Annulment 

Placement of Child for Adoption

Death of Dependent Child

Event Date

Service Requested



Cancel

Retiree

Coverage



Decrease Coverage



Cancel Dependent Child(ren) Coverage



Change Address

 Surviving Spouse

Coverage

Continuation

 Cancel Spouse Coverage  Change Name  Change Retiree

Premium Payment Method

If adding a spouse or child coverage as a result of a qualifying life event, an Enrollment Form or Evidence of Insurability Form must be completed.

canceling

or decreasing

coverage,

complete

ancel

Decrease

etails

below

For a

ll other changes,

complete the corresponding section below.

Surviving Spouse

Coverage

Continuation

Surviving Spouse Name:

Cancel/Decrease Details

Employee and spouse coverages are reduced by 50% of the active employee coverage. At age 75, employee and spouse coverages are

reduced by an additional 50%.

Coverage Type

Check only if you wish to

cancel or decrease

coverage

New Amount of Coverage

Requested (required)

Basic Group Term Life and AD&D



Cancel

$5,000

Expanded Basic Group Term Life and AD&D  Cancel  Decrease $

Supplemental Group Term Life and AD&D  Cancel  Decrease $

Spouse Supplemental Group Term Life and AD&D  Cancel  Decrease $

Dependent Child(ren) Supplemental Group Term Life and AD&D



Cancel



Decrease

Elected child(ren) coverage includes all eligible dependents. If cancelling, all dependent child(ren) coverage will be remove

Name Change

Current: Reason:  Marriage/Divorce 

Correction 

Other

A copy of legal documentation is required

unless your name is changing due to reason of marriage or divorce.

Address Change

Home Address

–

Street

City

State

Zip Code

Email Address Primary Phone No.

Secondary Phone No.

Select the retirement system in which you participate. Always complete. Check only one of the following:



ARDOT RETIREES SOA 091

(E5373097)



APERS STATE RETIREES 998 (E5381462)



ARTRS RETIREES SOA 999,059001 (E5381587)



S STATE RETIREES SOA

021 (E5381488)



APERS SCH RETIREES SOA 059002 (E5381470)



ADJR

STATE RETIREES SOA

(E5381496)



TATE OF A

R RETIR

RECT

BILL

(

E5381421)

, check and complete Premium Payment Method Change Section below.

Premium Payment Method Change

–

If your premiums will not be deducted from your retirement check, please

select

payment method

1.  Please deduct monthly premiums from my bank account.

1

- 5

6

- 10

11

- 15

16

- 20

21

- 26

Your draft will occur on one of the dates within the ra

nge you have selected.

Please include a voided check or provide:

Routing # ___________________________ Account #___________________________

_______________________________________________________________________

Signature of bank account owner (REQUIRED)



Please bill me directly. (Choose one of the

following):



Quarterly (3 times your monthly premium)



Semi

Annual (6

times your monthly premium)



Annual (12 times your monthly premium)

IPG for direct pay retiree policies (Internal use only):

I2058329

Last Revision 4.10.20 SOA RETIREE SERVICE

83364

Page 2 of 2

Authorization Section

If this form is not received by Colonial Life & Accident Insurance Company before the monthly pension deduction deadline, a direct bill will be mailed to

you. Failure to pay this bill may result in cancelled coverage. Once the initial bill is paid, monthly deductions from your pension check will automatically

begin. In the event my retirement annuity does not have sufficient funds for premium deduction, a Bank Draft Authorization form, along with a voided

check must be attached. Premiums paid will be post-tax. I understand that my elections can only be changed if I have a qualifying status change event

and that I must request such changes within 60 days of the qualifying event.

I hereby authorize you to deduct from my retirement check such amounts as necessary to pay the premiums for my life insurance plan. I further

authorize you to pay such amounts to the insurance company providing such insurance or its authorized representative. This authorization remains in

effect until you receive notice from me in writing that it has been changed or revoked.

_________________________________________________________ ____________________________________

Retiree Signature

Date (mm/dd/yyyy)

Group Term Life Insurance with Accidental Death &

Dismemberment (AD&D) Insurance for Retired* Employees

If something happened to you, would your family be able to maintain their

way of life? How would they cover ongoing living expenses? Colonial Life’s

group term life insurance can help provide financial security for your family.

Take action to retain your

group term life with AD&D

insurance coverage as a retiree.

Within 31 days of your

retirement date, submit a group

term life with AD&D service

form and payment authorization

form to Colonial Life via fax at

803-678-6861. The retiree

service form and beneficiary

designation form are available

at ARBenefits.org.

How secure is your family’s ﬁnancial future without you?

GTL WITH AD&D FOR RETIREES AFTER //

Why is group term life insurance a good option?

 Death benefit protection

 Lower cost option

 Coverage for specified periods of time, which can be during high-need years

 Benefit is typically paid tax-free to your beneficiaries

AD&D insurance provides benefits to help cover the additional expenses

associated with an accidental death, as well as the high costs of recovery

and rehabilitation required by an accidental dismemberment.

The AD&D full benefit amount is equal to your group term life insurance

death benefit amount.

The following benefits are paid under the AD&D benefit:

Additional benefits and services:

Seatbelts and Airbags – Pays if the cause of death or dismemberment is a car accident and if the

covered person was using a seatbelt or airbag.

Built-in accelerated death benefit provides an advance of up to 75% of the death benefit, to a

maximum of $150,000, if the covered person is diagnosed with a terminal illness.

Health Advocate employee assistance program provides 24-hour confidential personal

support and referral service, including a medical bill saver service. Face-to-face sessions and

video counseling with mental health professionals are available.

Life planning services oer financial and legal counseling services, as well as grief support and

referral for up to 12 months aer a claim.

*Includes Arkansas state and public school employees retired aer 1/1/2020.

If the loss is:

% of the full

amount paid

Loss of life 100%

Loss or loss of use of both hands or both feet or sight of both eyes 100%

Loss or loss of use of one hand and one foot 100%

Loss or loss of use of one hand and sight of one eye 100%

Loss or loss of use of one foot and sight of one eye 100%

Loss of speech and hearing 100%

Loss or loss of use of one hand or one foot 50%

Loss of sight of one eye 50%

Loss of speech or hearing 50%

Loss of thumb and index finger of the same hand 25%

 Terminal illness means an injury or sickness

that results in the covered person having a life

expectancy of 12 months or less and from which

there is no reasonable prospect of recovery.

 The Employee Assistance Program and

Life Planning Services, provided by Health

Advocate, are available with Colonial Life &

Accident Insurance Company’s Group Term

Life oering. Terms and availability of service

are subject to change. The service provider

does not provide legal advice; please consult

your attorney for guidance. Services are not valid

aer coverage terminates. Please contact the

company for full details.

ONLINE

ColonialLife.com/EAP

Telephone

1-888-645-1772

Coverage options Retiree coverage details. Retirees may not increase coverage amounts.

Basic group term life with AD&D insurance**

Upon retirement, coverage is reduced by 50% of the active employee coverage.

At age 75, coverage is reduced by an additional 50%.

Expanded basic group term life with AD&D insurance**

Upon retirement, coverage is reduced by 50% of the active employee coverage.

At age 75, coverage is reduced by an additional 50%.

Supplemental employee group term life with AD&D insurance **

Upon retirement, coverage is reduced by 50% of the active employee coverage.

At age 75, coverage is reduced by an additional 50%.

Supplemental spouse group term life with AD&D insurance

Upon retirement, spouse coverage is reduced by 50% of the active employee coverage.

At age 75, spouse coverage is reduced by an additional 50%.

Supplemental dependent child(ren) group term life with AD&D

insurance

No coverage reductions to dependent child(ren) coverage

Your basic and optional coverages

** At age 75, Basic, Expanded Basic and Supplemental Life Insurance may not exceed a combined face amount of $25,000, comprised of no more than $12,500 of

Basic and Expanded Basic combined and no more than $12,500 of Supplemental Life coverage.

2024 Retiree Rates* (per $1,000)

Monthly cost of coverage

Retiree supplemental group

term life with AD&D insurance

Age Employee

Under 50 $0.41

50-54 $0.66

55-59 $0.95

60-64 $1.43

65-69 $2.78

70-74 $ 4.53

75+ $ 9.03

Retiree supplemental spouse

group term life with

AD&D insurance

All

eligible ages

$1.28

Retiree supplemental

dependent child(ren) group

term life with AD&D insurance

All

eligible ages

$0.12

BENEFIT REDUCTION SCHEDULE

Retirees prior to 1/1/2020:

Refer to your certificate for benefit reduction details.

EXCLUSIONS AND LIMITATIONS

Losses Not Covered Under Your Life Insurance Benefit:

Your life insurance benefit does not cover any losses where death is caused by, contributed to by, or results from

suicide occurring within 24 months aer a covered person’s initial eective date of insurance or aer the date any

increases or additional insurance becomes eective, whether sane or insane.

This applies to any amounts of insurance for which you pay all or part of the premium.

This applies to any amount subject to evidence of insurability requirements and we approve the evidence of

insurability form and the amount you applied for at that time.

You will be given credit for any period of time applied toward the satisfaction of the suicide provision, if any, under

your Employer’s prior group life insurance plan.

Losses Not Covered Under the AD&D Insurance Benefit:

Your AD&D benefit does not cover any losses that are caused by, contributed to by, or resulting from:

• an attempt to commit or commission of suicide or intentional self-inflicted injury while sane or insane;

• active participation in a riot;

• an attempt to commit or commission of a felony or engaging in an illegal occupation;

• voluntary use of any drugs, poisonous substance, intoxicant or narcotic, except any drugs taken as prescribed

by a physician and taken as prescribed. Accidental exposure to any poisonous substance will not be excluded;

• the presence of that percentage of alcohol in the covered person’s blood which raises a presumption that the

covered person was under the influence of alcohol. The blood-alcohol level which raises this presumption is

governed by the laws of the state in which the accident occurred;

• disease of the body, mental infirmity or diagnostic, medical or surgical treatment;

• being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or

authority. Losses as a result of acts of terrorism or nuclear release committed by individuals or groups will not

be excluded from coverage unless the covered person who suered the loss committed the act of terrorism or

nuclear release; or

• investigational or experimental procedures, surgery, or drugs, including complications arising from having

experimental or investigative procedures, surgeries, or drugs.

Termination

Coverage terminates:

• if the group policy ends;

• the date you no longer meet eligibility requirements;

• the end of the grace period if we do not receive the required premium for your insurance; or

• the date the next premium is due aer you ask us to end your coverage.

Premium will vary based on plan options and face amount.

Applicable to policy number GTL1.0-P-AR-SOA and certificate number GTL1.0-C-AR-SOA.

This is not an insurance contract and only the actual policy provisions will control.

Retiree basic and expanded

basic group term life with

AD&D insurance

$1.13 per $1,000

23 | NS-361903-3

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC

is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

*Includes Arkansas state and public

school employees retired aer 1/1/2020.

Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. | ColonialLife.com

| 2-20 | NS

-368601

Colonial Life | CHANGE OF BENEFICIARY | Fax: 803-678-6861 | Telephone: 855-868-6009

State of Arkansas Change of Beneﬁciary Form

FAX this direction

Fax this form: 803-678-6861

Or mail: P.O. Box 1365, Columbia, SC 29202

From:

Number of pages:

I am changing the following: £ Primary Beneﬁciary £ Contingent Beneﬁciary £ Both (If no box is checked, the form will be reviewed only for the beneﬁciary designations listed.)

Insured’s name:

First:

Middle Initial:

Last:

SSN: DOB: ____ / ____ / ________ Telephone: Email:

Address: City: State: ZIP:

Policy number(s):

General

Information

Naming a Minor as a Beneﬁciary: In some instances, Colonial Life may not be able to pay life insurance proceeds to a minor beneﬁciary unless a court appointed adult guardian,

conservator or custodian has been properly designated for the minor’s property in advance planning documents. When Colonial Life is unable to disperse beneﬁts in such situations,

Colonial Life will hold the proceeds (with interest earned on the funds) until the minor reaches the age of majority. If you have questions about the consequences of naming a minor as

a beneﬁciary, feel free to discuss with a legal or estate planning professional.

Naming a Trust: Provide the name of the trust, the date the trust was established, and the address of where the trust is held.

Naming a Funeral Home: Provide the name, full address, and the owner or authorized personnel of the funeral home. Write “As Interest May Appear” and designate another primary

beneﬁciary to receive any remaining beneﬁts available after the funeral home’s expenses have been paid.

Primary beneﬁciary(ies)

All ﬁelds must be completed for each beneﬁciary. Unless otherwise speciﬁed, proceeds will be paid in equal shares to surviving beneﬁciaries.

If selecting more than one Primary Beneﬁciary, the percentages must equal 100%. Attach additional pieces of paper if more space is needed.

First: Middle initial: Last: Percentage

DOB: _____ / _____ / __________ SSN: Telephone:

Address: City: State: ZIP:

First: Middle initial: Last: Percentage

DOB: _____ / _____ / __________ SSN: Telephone:

Address: City: State: ZIP:

First: Middle initial: Last: Percentage

DOB: _____ / _____ / __________ SSN: Telephone:

Address: City: State: ZIP:

First: Middle initial: Last: Percentage

DOB: _____ / _____ / __________ SSN: Telephone:

Address: City: State: ZIP:

Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. | ColonialLife.com

| 2-20 | NS

-368601

Colonial Life | CHANGE OF BENEFICIARY | Fax: 803-678-6861 | Telephone: 855-868-6009

Contingent beneﬁciary(ies)

If at the time of the insured’s death and all primary beneﬁciaries are disqualiﬁed or die before the insured, proceeds will be paid to

the contingent beneﬁciaries listed in equal shares. If selecting more than one contingent beneﬁciary, the percentage must equal 100%.

Attach additional pieces of paper if more space is needed.

First: Middle initial: Last: Percentage

DOB: _____ / _____ / __________ SSN: Telephone:

Address: City: State: ZIP:

First: Middle initial: Last: Percentage

DOB: _____ / _____ / __________ SSN: Telephone:

Address: City: State: ZIP:

First: Middle initial: Last: Percentage

DOB: _____ / _____ / __________ SSN: Telephone:

Address: City: State: ZIP:

First: Middle initial: Last: Percentage

DOB: _____ / _____ / __________ SSN: Telephone:

Address: City: State: ZIP:

Required signature (complete this section in its entirety)

________________________________________________________________________________________________ ______________________________________________

Signature of policy owner Date (MM/DD/YYYY)

Print policy owner name: SSN:

DOB: ____ /____ / ________ Telephone: Email:

Address: City: State: ZIP:

Special Notice for Residents of a Community Property State: A spouse or former spouse may have an interest in life insurance proceeds or any accumulated cash

value if the policy premiums were paid with community funds. It is your responsibility to consult your legal advisor to 1) ensure that any required consent from a spouse

or former spouse has been received and 2) ensure that your spouse or former spouse will not be able to make a claim against any policy values and/or proceeds in the

event any policy beneﬁts become payable.

PREVENTIVE AND

DIAGNOSTIC

• Two routine exams

per beneﬁt period

• X-rays

• Two cleanings per

beneﬁt period

• Two ﬂuoride applications

for dependent children

up to age 19

• Sealants for dependent

children up to age 16

BASIC RESTORATIVE

SERVICES

• Minor emergency

treatment

• Fillings

• Simple extractions

• Space maintainers for

dependent children

up to age 14

• Stainless steel crowns

for dependent children

up to age 16

MAJOR RESTORATIVE

SERVICES

• Crowns

• Endodontics (root canals)

Oral surgery

• Dentures, bridges,

partials

WHAT’S COVERED?

DENTAL

AND

VISION

PLANS

State of Arkansas

Retiree Program

Individual and familiy

plans at a price that will

make you smile.

Individual & Family Application | Plan number SOARR01

APPLICANT INFORMATION

Name: Date of Birth: £ Male £ Female

Mailing Address: City: State: ZIP:

Social Security #: Home Number:

Email: Mobile Number:

PLAN SELECTION (CHOOSE ONE)

£ Dental £ Dental and Vision

TYPE OF COVERAGE (CHOOSE ONE)

£ Individual £ Individual and Spouse £ Individual and Child(ren) £ Individual and Family

DEPENDENTS

First Name Last Name Social Security # Date of Birth Sex

Spouse

Child

PREVIOUS COVERAGE

Will this replace

existing

dental coverage?

£ YES £ NO

If you are purchasing this coverage to replace an existing Delta Dental of Arkansas plan, please provide

the anticipated termination date of your current plan:_______________________________________

If the coverage will replace a plan with another carrier, please submit a copy of the Certiﬁcate of

Creditable Coverage and a list of covered beneﬁts. A Certiﬁcate of Creditable Coverage beneﬁts can

be obtained from your previous insurance carrier on your employer group health administrator.

HOUSEHOLD RESIDENTIAL INFORMATION

Do all proposed insured reside in Arkansas? £ YES £ NO If no, provide reason:

PAYMENT METHOD - BANK DRAFT OR CREDIT CARD ONLY (DO NOT SEND A LIVE CHECK)

Bank Draft: £ Monthly £ Annually Routing Number:________________________________

Bank Account: £ Checking £ Savings Account Number:________________________________

I authorize Delta Dental of Arkansas (DDAR) and the BANK* indicated above to debit my DDAR premium from my checking or savings

account indicated above. This authority is to remain in full force and eect until my BANK has received written notiﬁcation from me of

the Pre-Authorized Bank Draft Program termination in such a time and such a manner as to aord the BANK a reasonable opportunity

to act on it, or until the BANK has sent me ten (10) day written notice of the BANK's termination of this agreement.

I understand that by revoking the Pre-Authorization Bank Draft Program after I have agreed to it, I will also be terminating my DDAR

coverage, unless DDAR has received written notice from me of my desire to continue coverage at least twenty (20) days prior to the

next Pre-Authorization Bank Draft Program date.

____________________________________________________________________ ___________________________

Signature of Bank Account Holder Date

Monthly bank drafts are processed on the 5th of each month. *BANK also applies to Savings and Loan.

REQUESTED EFFECTIVE DATE

MONTH DAY

YEAR

MAIL TO: H&H Beneﬁts Specialists

1301 West 7th Street

Little Rock, AR 72201

Include a voided

check with application.

Rates eective:

October 1, 2019 — December 31, 2022

SOARR12-2019

Easy access

We make it easy for you to

access the information you

need at any time. Through

our website, you can:

• Locate a dentist

• Check claims status

and history

• Review plan coverage

• Print ID cards,

• and more!

FREQUENTLY ASKED

QUESTIONS

Who is eligible for coverage under a Delta Dental

Individual and Family plan?

You must be an Arkansas resident and a State of

Arkansas Retiree Program member to be eligible for

coverage. Acceptance is guaranteed regardless of

age, dental history or pre-existing conditions.

What are the age limitations for dependent

children?

Dependent children can continue coverage until the

end of the month in which they turn 26.

What services are NOT covered under this plan?

For a complete list of services not covered, please

visit our website to view the Schedule of Beneﬁts.

General services that are not covered include:

• Tooth implants

• Tooth whitening

• Athletic mouth guards

• Braces and retainers

• Treatment for TMJ (temporomandibular

joint disturbances)

• Services to correct cosmetic dentistry

• Dental care started prior to the date the patient

became covered under this plan

DeltaDentalAR.com

1513 Country Club Road, Sherwood, AR 72120.

Why Delta Dental?

Dental insurance is not a sideline

of our business — it is the heart.

We are the state’s largest and

most experienced dental insurance

company, and our expertise is why

nearly 2 million members across the

country trust their smiles to Delta

Dental of Arkansas.