FORMS

BENEFICIARY

To update a beneficiary, please visit yes.az.gov

ENROLLMENT FORMS & GUIDES

Active Employees
Enrollment is entirely online via yes.az.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/Applications
  • Enrollment Form - Active 2020
  • Declaration for Change Form - Active 2020
  • Appeal Form - Active 2020
     

Retirees/LTD 

• 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
  • 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

• Transition of Care Form - 2020

PHARMACY

 MedImpact - Active

• MailOrder Pharmacy Form - Active

Vibrant Rx - Retiree

• Medicare PDP Enrollment Form VibrantRx 2020 - Retiree