Employee Benefit Plans

Benefit Plan Documents & Forms

Medical Plan Booklets

Effective January 1, 2020 – December 31, 2020

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

Base Booklet 2020 – 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

Medical Plan Booklets

Effective January 1, 2019 – December 31, 2019

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

Base Booklet 2019 – Statewide Network – All Plans

Base Booklet 2019 – Alliance Network – All Plans

Domestic Partner Rider Insert (applicable only if elected at group level)

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

  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
• 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
• HSA Series

  Alliance

  • HSA 1500
  • HSA 2700
  • HSA 3500
  • HSA 4500
  • HSA 6750

  Statewide

  • HSA 1500
  • HSA 2700
  • HSA 3500
  • HSA 4500
  • HSA 6750

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 Summaries

Effective January 1, 2020 – December 31, 2020

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, 2019 – December 31, 2019

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
• 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
• HSA Series

  Alliance

  • HSA 1500
  • HSA 2700
  • HSA 3500
  • HSA 4500
  • HSA 6750

  Statewide

  • HSA 1500
  • HSA 2700
  • HSA 3500
  • HSA 4500
  • HSA 6750

Dental Plans -  Summary and Booklets

BlueCross BlueShield Arizona

Vision Plan Summaries

VSP

Life / AD&D Plan Summaries

The Standard Insurance Company