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FORMS

AFFORDABLE CARE ACT | 1095C Reprint Form

  • Affordable Care Act (ACA) page
  • Form 1095-C Reprint Request

BENEFICIARY

  • To update a beneficiary, please visit hrsystems.azdoa.gov > YES Portal > Your Employee Benefits > Benefits > Beneficiaries.
  • State Employee Information Organizer (Being Prepared) - This guide from Human Resources provides information on steps for your loved ones to take in the event you pass away while employed by the State.

ENROLLMENT FORMS & GUIDES 

For active employees, enrollment is entirely online via hrsystems.azdoa.gov > YES Portal.

Active Employees 

  • Guides
    • Active Enrollment Guide - with enrollment instructions and a simple explanation of each benefit - includes current rates. 2023
    • Active Benefits Guide - an in-depth look at your benefits to help you use your plan effectively - includes current rates. | 2022 | 2023 available by January 15.
  • Forms
    • Active Enrollment Form | 2023
    • Active Appeal Form | 2023
    • Declaration for Change Form
       
  • Qualified Life Event (QLE)
    • The following events can be processed online: birth, adoption, marriage, divorce, and legal separation. See the QLE page.
      • Qualified Life Event (QLE) and Mid-Year Changes Chart
      • Age 26 Dependent Termination Process

Retirees/LTD 

  • Guides
    • Retiree Enrollment Guide - With enrollment instructions and a simple explanation of each benefit - includes current rates. | 2022 | 2023
    • Retiree Benefits Guide - An in-depth look at your benefits to help you use your plan effectively - includes current rates. | 2022 | 2023 available by January 31
  • Forms
    • Retiree/LTD Enrollment Form |  2023 
    • Medicare PDP Enrollment Form Vibrant Rx | 2022 | 2023
    • Retiree Appeal Form | 2022 | 2023

COBRA

  • Visit the COBRA tab

FLEXIBLE SPENDING ACCOUNTS | FSA

  • FSA Healthcare - for use with Triple Choice Plan | 2022| 2023
  • FSA Limited Purpose (Dental & Vision) - for use with High Deductible Healthcare Plan (HDHP w/HSA) | 2022 | 2023
  • FSA Daycare/Eldercare | 2022 | 2023

HEALTH CARE SPENDING ACCOUNT | HSA

For use with a high deductible healthcare plan (HDHP).  

Forms

  • HSA Payroll Deduction Authorization Form | 2022 | 2023
  • How to Calculate HSA Contributions and Maximum Contributions Guide | 2022
  • HSA Contribution Cancellation Request Form
  • HSA Excess Contribution Cancellation Request Form
  • HSA Transfer Account to Optum Bank Form

PRESCRIPTION DRUG | PHARMACY

  • Active - MedImpact Mail Order Pharmacy Form 
  • Active - MedImpact Reimbursement Form
  • Retiree - Vibrant Rx Medicare PDP Enrollment Form | 2022 | 2023
  • Retiree - Vibrant Rx Medicare PDP Disenrollment Form | 2022 | 2023


COVID At-Home Test Reimbursement

  • Reimbursement Rules
  • Blue Cross Blue Shield COVID At-Home Test Reimbursement Form
  • UnitedHealthcare COVID At-Home Test Reimbursement Form 

TRANSITION OF CARE

  • Transition of Care | 2023
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Contact Us
ADOA | HR-Benefit Services Division
100 N. 15th Ave., Ste. 301
Phoenix, AZ 85007
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Phone: 602-542-5008
Fax: 602-542-4744
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