FORMS

• 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. | 2022
  • Active Benefits Guide - an in-depth look at your benefits to help you use your plan effectively - includes current rates. | 2022 
• Forms
  • Active Enrollment Form | 2022
  • Active Appeal Form | 2022
  • Declaration for Change Form
     
• Qualified Life Event (QLE)
  • 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
  • Retiree Benefits Guide - An in-depth look at your benefits to help you use your plan effectively - includes current rates. | 2022 
• Forms
  • Retiree/LTD Enrollment Form | 2022
  • Medicare PDP Enrollment Form Vibrant Rx | 2022
  • Retiree Appeal Form | 2022

COBRA

• Visit the COBRA tab

FLEXIBLE SPENDING ACCOUNTS | FSA

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

HEALTH CARE SPENDING ACCOUNT | HSA

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

Forms

• HSA Payroll Deduction Authorization Form | 2022
• 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 Form | 2022 

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 | 2022