FORMS
BENEFICIARY
To update a beneficiary, please visit yesportal.azdoa.gov.
2020 ENROLLMENT FORMS & GUIDES
FOR OPEN ENROLLMENT 2021 INFORMATION - BEGIN HERE
Active Employees - 2020
Enrollment is entirely online via yesportal.azdoa.gov
- Guides
- Active Enrollment Guide 2020 - Guide with enrollment instructions and a simple explanation of each benefit - includes current rates.
- Active Benefits Guide 2020 - An in-depth look at your benefits to help you use your plan effectively - includes current rates.
- Forms
- Enrollment Form - Active 2020
- Declaration for Change Form - Active 2020- This is NOT the 2021 form for Open Enrollment. There is no paper form for Open Enrollment 2021. You must enroll online. Begin here.
- Appeal Form - Active 2020
Retirees/LTD - 2020
- Guides
- Retiree Enrollment Guide 2020Guide with enrollment instructions and a simple explanation of each benefit - includes current rates.
- Retiree Benefits Guide 2020 - An in-depth look at your benefits to help you use your plan effectively - includes current rates.
- Forms
- Enrollment Form - Retiree/LTD 2020 - This is NOT the 2021 form for Open Enrollment. There is no paper form for Open Enrollment 2021. You must enroll online. Begin here.
- Medicare PDP Enrollment Form VibrantRx - Retiree 2020
- Appeal Form - Retiree 2020
COBRA
- Visit the COBRA tab
QUALIFIED LIFE EVENTS | QLE
Please see our Qualified Life Events page for forms and filing information.
FLEXIBLE SPENDING ACCOUNTS | FSA
- FSA Enrollment Form - EPO & PPO | Dependent Care - 2020
- FSA Enrollment Form - HDHP - Limited Purpose for Dental & Vision | Dependent Care - 2020
HEALTH CARE SPENDING ACCOUNT | HSA
For use with a high deductible healthcare plan (HDHP).
- HSA Payroll Deduction Authorization Form - 2020
- How to Calculate Contributions and HSA Maximum Contributions - 2020
- HSA Excess Contributions or Close Account Form - 2020
MEDICAL
PHARMACY
MedImpact - Active
Vibrant Rx - Retiree
