Forms & Guides

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

You can also enroll online via hrsystems.azdoa.gov > YES Portal 

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. | 2023 | 2024
    • Retiree Benefits Guide - An in-depth look at your benefits to help you use your plan effectively - includes current rates. | 2023 | 2024

    Forms

    ADOA - BENEFITS

    If you have an appeal or grievance with ADOA-Benefits, use the Active and Retiree Forms linked 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 fill out this form.