Employee Benefit Plans

Benefit Plan Documents & Forms

Medical Plan Summaries

Effective January 1, 2022 – December 31, 2022

BlueCross BlueShield of Arizona
80 Series, 70 Series, HSA Series

• 80 Series

  Alliance

  • PPO 500
  • PPO 750
  • PPO 1000
  • PPO 1500
  • PPO 2000
  • PPO 2500
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000

  Statewide

  • PPO 500
  • PPO 750
  • PPO 1000
  • PPO 1500
  • PPO 2000
  • PPO 2500
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000

  Pima

  • PPO 500
  • PPO 750
  • PPO 1000
  • PPO 1500
  • PPO 2000
  • PPO 2500
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000
• 70 Series

  Alliance

  • PPO 1000
  • PPO 2000
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000

  Statewide

  • PPO 1000
  • PPO 2000
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000

  Pima

  • PPO 1000
  • PPO 2000
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000
• HSA Series

  Alliance

  • HSA 1500
  • HSA 2800
  • HSA 3500
  • HSA 4500
  • HSA 6900

  Statewide

  • HSA 1500
  • HSA 2800
  • HSA 3500
  • HSA 4500
  • HSA 6900

  Pima

  • HSA 1500
  • HSA 2800
  • HSA 3500
  • HSA 4500
  • HSA 6900

Medical Plan Summaries

Effective January 1, 2021 – December 31, 2021

BlueCross BlueShield of Arizona
80 Series, 70 Series, HSA Series

• 80 Series

  Alliance

  • PPO 500
  • PPO 750
  • PPO 1000
  • PPO 1500
  • PPO 2000
  • PPO 2500
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000

  Pima

  • PPO 500
  • PPO 750
  • PPO 1000
  • PPO 1500
  • PPO 2000
  • PPO 2500
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000

  Statewide

  • PPO 500
  • PPO 750
  • PPO 1000
  • PPO 1500
  • PPO 2000
  • PPO 2500
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000
• 70 Series

  Alliance

  • PPO 1000
  • PPO 2000
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000

  Pima

  • PPO 1000
  • PPO 2000
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000

  Statewide

  • PPO 1000
  • PPO 2000
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000
• HSA Series

  Alliance

  • HSA 1500
  • HSA 2800
  • HSA 3500
  • HSA 4500
  • HSA 6900

  Pima

  • HSA 1500
  • HSA 2800
  • HSA 3500
  • HSA 4500
  • HSA 6900

  Statewide

  • HSA 1500
  • HSA 2800
  • HSA 3500
  • HSA 4500
  • HSA 6900

Medical Plan Booklets

Effective January 1, 2021 – December 31, 2021

BlueCross BlueShield of Arizona
80 Series, 70 Series, HSA Series

Base Booklet 2021 – Statewide Network – All Plans

Note: The complete Benefit Booklet is comprised of both the above Base Booklet for your plan’s network (Statewide or Alliance) and the applicable plan attachment listed below.

• 80 Series
  • PPO 500
  • PPO 750
  • PPO 1000
  • PPO 1500
  • PPO 2000
  • PPO 2500
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000
• 70 Series
  • PPO 1000
  • PPO 2000
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000
• HSA Series
  • HSA 1500
  • HSA 2800
  • HSA 3500
  • HSA 4500
  • HSA 6900

Medical Plan Booklets

Effective January 1, 2022 – December 31, 2022

BlueCross BlueShield of Arizona
80 Series, 70 Series, HSA Series

Base Booklet 2022 – All Networks – All Plans

Note: The complete Benefit Booklet is comprised of both the above Base Booklet (which applies to all plans and all networks) and the applicable plan attachment listed below.

• 80 Series
  • PPO 500
  • PPO 750
  • PPO 1000
  • PPO 1500
  • PPO 2000
  • PPO 2500
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000
• 70 Series
  • PPO 1000
  • PPO 2000
  • PPO 3000
  • PPO 4000
  • PPO 5000
  • PPO 6000
• HSA Series
  • HSA 1500
  • HSA 2800
  • HSA 3500
  • HSA 4500
  • HSA 6900

Dental Plans -  Summaries and Booklets

BlueCross BlueShield Arizona

Dental Summary Overview

• Booklets
  • DHMO High Booklet
  • PPO 50|1000 Booklet
  • PPO 50|1500 Booklet
  • PPO 50|1500 with Adult & Child Ortho Booklet
  • PPO 50|1500 P290 Optimum Booklet
  • PPO 50|1000 A90 Value Booklet
• Summaries
  • DHMO High Summary
  • PPO 50|1000 Summary
  • PPO 50|1500 Summary
  • PPO 50|1500 with Adult & Child Ortho Booklet
  • PPO 50|1500 P290 Optimum Summary

  • PPO 50|1000 A90 Value Booklet

Vision Plan Summaries

VSP

Life / AD&D Plan Summaries

Equitable