Forms & Guides

Guides

• Active Enrollment Guide - With enrollment instructions and a simple explanation of each benefit - includes current rates | 2025
• Active Benefits Guide - An in-depth look at your benefits to help you use your plan effectively - includes current rates | 2025

Enrollment Forms

• Active Enrollment Form | 2025
• Additional Dependents Form

Flexible Spending Accounts | FSAs

• FSA Healthcare - for use with the Triple Choice Plan | 2025
• FSA Limited Purpose (Dental and Vision) - for use with High Deductible Healthcare Plan (HDHP w/HSA) | 2025
• FSA Daycare/Eldercare | 2025

Healthcare Spending Account | HSA

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

• HSA Payroll Deduction Authorization Form | 2025
• How to Calculate HSA Contributions Guide | 2025
• HSA Employer Contribution Cancellation Request Form
• HSA Employee Excess Contribution Cancellation Request Form
• HSA Transfer Account (Rollover) to Optum Bank Form

Guides

• Retiree Enrollment Guide - With enrollment instructions and a simple explanation of each benefit - including current rates. | 2025
• Retiree Benefits Guide - An in-depth look at your benefits to help you use your plan effectively - includes current rates. | 2025

Forms

• Retiree/LTD Enrollment Form | 2025
  • When you enroll as a retiree, you establish a new account, and ADOA closes your employee account. You must re-submit supporting documents, such as marriage and birth certificates, for your covered dependents since we cannot transfer them to your retirement account. If you are enrolled in Medicare, include your Medicare card or entitlement letter.
• Retiree Vibrant Rx Prescription Drug Plan Enrollment Form | 2025
• 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

• Active Form | 2025 - For faster service, open a ticket in ServiceNow under the Benefit Services tab to track your request and receive updates. If you are unable to access ServiceNow, email your documents to [email protected].
• Retiree Form | 2025

CARRIER CLAIM CONTACTS

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

• Avesis Vision - call 888-759-9772
• BlueCross BlueShield of Arizona (BCBSAZ)
• Delta Dental 
• Securian Life - call 833-745-5517
• MetLife Short-Term Disability 
• UnitedHealthcare (UHC) - Medical
• UnitedHealthcare (UHC) Solstice Dental - call 844-208-0223

• Affordable Care Act (ACA) page
• Form 1095-C Reprint Request - Forms are mailed in February. Requests are accepted after March 1.
• For ACA questions - contact [email protected].

• To update a beneficiary, please visit hrsystems.azdoa.gov > YES Portal > Your Employee Benefits > Benefits > Beneficiaries.
• For coverage information, visit our Life Insurance page.
• 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.

• Visit the COBRA tab for full information.

• 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. 

• Transition of Care Form