Forms & Guides

All the forms and guides you need to enroll are listed here.

Enroll Online 

 

Guides

  • Active Enrollment Guide - With enrollment instructions and a simple explanation of each benefit - includes current rates | 2024
  • Active Benefits Guide - An in-depth look at your benefits to help you use your plan effectively - includes current rates | 2024

Enrollment Forms


Flexible Spending Accounts | FSAs

  • FSA Healthcare - for use with the Triple Choice Plan | 2024
  • FSA Limited Purpose (Dental and Vision) - for use with High Deductible Healthcare Plan (HDHP w/HSA) | 2024
  • FSA Daycare/Eldercare | 2024

Healthcare Spending Account | HSA

This account is for use with a high-deductible healthcare plan (HDHP).  


    Guides

    • Retiree Enrollment Guide - With enrollment instructions and a simple explanation of each benefit - including current rates. | 2024
    • Retiree Benefits Guide - An in-depth look at your benefits to help you use your plan effectively - includes current rates. | 2024

    Forms

    • Retiree/LTD Enrollment Form | 2024
      • Note: When you enroll as a retiree, you establish a new account, and ADOA closes your employee account. This means you must re-submit supporting documents, such as marriage and birth certificates, for your covered dependents since we cannot transfer them to your retiree account. If you are enrolled in Medicare, include your Medicare card or entitlement letter.
    • Retiree Vibrant Rx PDP Enrollment Form | 2024
    • Retiree Vibrant Rx PDP Disenrollment Form

    ADOA - BENEFITS

    If you have an appeal or grievance with ADOA-Benefits, use the Active and Retiree Forms below. 

    • Appeals - Eligibility, missed enrollment deadlines, and technical issues with HRIS/Y.E.S. (Carrier claim appeals, see below).
    • Grievances - Dissatisfaction with care, the insurance plan, a provider, or access to care. Inconsistent application of State statute or rule by ADOA-Benefits as listed on benefitoptions.az.gov/administrative-rules.

    FORMS


    CARRIER CLAIM CONTACTS

    To file an appeal for a claim denied by a carrier, use the information below.

     

    • Please note that the coverages described in the retiree guides above apply to you. 
    • The only difference is that LTD enrollees are considered direct pay members.
    • PSPRS, CORP, and EORP participants - pay the full premiums as shown in the guides.
    • ASRS participants - receive a subsidy based on years of service. Please refer to the guides for more information.
    • You will also use the retiree/LTD enrollment form found above.

    If you are changing carriers or moving from an out-of-network provider to an in-network provider, please complete this form.