Forms & Guides
All the forms and guides you need to enroll are listed here.
You can also enroll online via hrsystems.azdoa.gov > YES Portal
Guides
- Active Enrollment Guide - With enrollment instructions and a simple explanation of each benefit - includes current rates | 2024
- Active Benefits Guide - An in-depth look at your benefits to help you use your plan effectively - includes current rates | 2024
Enrollment Forms
- Active Enrollment Form 2024
- Additional Dependents Form
Flexible Spending Accounts | FSAs
- FSA Healthcare - for use with the Triple Choice Plan | 2024
- FSA Limited Purpose (Dental and Vision) - for use with High Deductible Healthcare Plan (HDHP w/HSA) | 2024
- FSA Daycare/Eldercare | 2024
Healthcare Spending Account | HSA
This account is for use with a high-deductible healthcare plan (HDHP).
- HSA Payroll Deduction Authorization Form | 2024
- How to Calculate HSA Contributions and Maximum Contributions Guide | 2024
- 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. | 2023 | 2024
- Retiree Benefits Guide - An in-depth look at your benefits to help you use your plan effectively - includes current rates. | 2023 | 2024
Forms
- Retiree/LTD Enrollment Form | 2024
- Retiree Vibrant Rx PDP Enrollment Form | 2024
- Retiree Vibrant Rx PDP Disenrollment Form
ADOA - BENEFITS
If you have an appeal or grievance with ADOA-Benefits, use the Active and Retiree Forms linked 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
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.
- 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.
- 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 fill out this form.