For Brokers.

Program Information

Broker Onboarding Guide
Benefits Program Employer Guide

Benefits Program Information

General Information

Health Program Overview
Health Program Plan Descriptions 2021
Broker Commission ACH Form
Group Administrative Guide
Video: BCBSAZ’s Comprehensive Association Health Plan

HSA/FSA

HSA Product Portfolio
FSA Product Portfolio
HSA/FSA FAQs
HAS/FSA Implementation Guide
Plan Implementation Presentation

New Group Setup Paperwork

New Group Setup Application and Forms

New Group Setup Checklist
Group Master Application – 2021
Enrollment Census Template
Employee Enrollment Form – 2021
EFT Authorization Form
SIMON Access Request Form
Unemployment Tax & Wage Report Form

Medical Plan Information – Blue Cross Blue Shield of Arizona

2021 Plan Year
Summary of Benefit Coverages

Statewide
AZTC 2021 PPO 100/5000
AZTC 2021 PPO 100/7900
AZTC 2021 PPO 90/500
AZTC 2021 PPO 90/1000
AZTC 2021 PPO 80/500
AZTC 2021 PPO 80/750
AZTC 2021 PPO 80/1000
AZTC 2021 PPO 80/1500
AZTC 2021 PPO 80/2000
AZTC 2021 PPO 80/2500
AZTC 2021 PPO 80/3000
AZTC 2021 PPO 80/4000
AZTC 2021 PPO 80/5000
AZTC 2021 PPO 80/6000
AZTC 2021 PPO 70/1000
AZTC 2021 PPO 70/2000
AZTC 2021 PPO 70/3000
AZTC 2021 HSA 80/1500
AZTC 2021 HSA 80/3000
AZTC 2021 HSA 80/4500
AZTC 2021 HSA 100/3500
AZTC 2021 HSA 100/6900

PimaConnect
AZTC 2021 PPO 100/5000 PimaConnect
AZTC 2021 PPO 100/7900 PimaConnect
AZTC 2021 PPO 90/500 PimaConnect
AZTC 2021 PPO 90/1000 PimaConnect
AZTC 2021 PPO 80/500 PimaConnect
AZTC 2021 PPO 80/750 PimaConnect
AZTC 2021 PPO 80/1000 PimaConnect
AZTC 2021 PPO 80/1500 PimaConnect
AZTC 2021 PPO 80/2000 PimaConnect
AZTC 2021 PPO 80/2500 PimaConnect
AZTC 2021 PPO 80/3000 PimaConnect
AZTC 2021 PPO 80/4000 PimaConnect
AZTC 2021 PPO 80/5000 PimaConnect
AZTC 2021 PPO 80/6000 PimaConnect
AZTC 2021 PPO 70/1000 PimaConnect
AZTC 2021 PPO 70/2000 PimaConnect
AZTC 2021 PPO 70/3000 PimaConnect
AZTC 2021 Saver HSA 80/1500 PimaConnect
AZTC 2021 Saver HSA 80/3000 PimaConnect
AZTC 2021 Saver HSA 80/4500 PimaConnect
AZTC 2021 Saver HSA 100/3500 PimaConnect
AZTC 2021 Saver HSA 100/6900 PimaConnect

Alliance
AZTC 2021 PPO 100/5000 SBC Alliance
AZTC 2021 PPO 100/7900 SBC Alliance
AZTC 2021 PPO 90/500 SBC Alliance
AZTC 2021 PPO 90/1000 SBC Alliance
AZTC 2021 PPO 80/500 SBC Alliance
AZTC 2021 PPO 80/750 SBC Alliance
AZTC 2021 PPO 80/1000 SBC Alliance
AZTC 2021 PPO 80/1500 SBC Alliance
AZTC 2021 PPO 80/2000 SBC Alliance
AZTC 2021 PPO 80/2500 SBC Alliance
AZTC 2021 PPO 80/3000 SBC Alliance
AZTC 2021 PPO 80/4000 SBC Alliance
AZTC 2021 PPO 80/5000 SBC Alliance
AZTC 2021 PPO 80/6000 SBC Alliance
AZTC 2021 PPO 70/1000 SBC Alliance
AZTC 2021 PPO 70/2000 SBC Alliance
AZTC 2021 PPO 70/3000 SBC Alliance
AZTC 2021 Saver HSA 80/1500 SBC Alliance
AZTC 2021 Saver HSA 80/3000 SBC Alliance
AZTC 2021 Saver HSA 80/4500 SBC Alliance
AZTC 2021 Saver HSA 100/3500 SBC Alliance
AZTC 2021 Saver HSA 100/6900 SBC Alliance

Benefit Booklets

2021 Arizona Technology Council Base Benefit Booklet

Plan Specific Attachments

AZTC PPO 100/5000
AZTC PPO 100/7900
AZTC PPO 90/500
AZTC PPO 90/1000
AZTC PPO 80/500
AZTC PPO 80/750
AZTC PPO 80/1000
AZTC PPO 80/1500
AZTC PPO 80/2000
AZTC PPO 80/2500
AZTC PPO 80/3000
AZTC PPO 80/4000
AZTC PPO 80/5000
AZTC PPO 80/6000
AZTC PPO 70/1000
AZTC PPO 70/2000
AZTC PPO 70/3000
AZTC HSA 80/1500
AZTC HSA 80/3000
AZTC HSA 80/4500
AZTC HSA 100/3500
AZTC HSA 100/6900

Medical Marketing Material

Welcome Guide for New BCBSAZ Members
Video: BCBSAZ’s Comprehensive Association Health Plan
2021 Medical and Dental Plan Product Guide
AZTC Medical/Dental Flyer
BlueCare Anywhere Telehealth App
Find a Doctor Tool
Seeking Care Away from Home
PayForward Cash Back Rewards Program
Mobilize AZ Diabetes: Get Smart about Diabetes
Welvie Online Program: To guide you through the surgery decision making process

Commonly Used Forms

Appeal Grievance Request Form
Domestic Partner Affidavit
Mail-order Pharmacy Form

Dental Plan Information – Blue Cross Blue Shield of Arizona

2021 Plan Year
Dental Plan Summaries

AZTC DHMO High
AZTC PPO 50-1000 A Value
AZTC PPO 50-1500 A Value
AZTC PPO 50-1500 A2 Optimum
AZTC PPO 25-2000 A2 Optimum w/ 1500 Adult/Child Ortho

Dental Marketing Material

Why Buy BlueDental
BlueDental Plan Brochure

Vision Plan Information – VSP

2021 Plan Year
Group Vision Care Policy

Evidence of Coverage: Group Vision Care Policy

Vision Benefit Summaries

VSP Vision Basic Plan with Suncare
VSP Vision Easy Options Plan
VSP Vision Enhanced Plan with Suncare
VSP Vision Exam Plus Plan
VSP Vision Preferred with Suncare

Vision Marketing Material

VSP Network Providers
VSP Freedom to Choose Overview
VSP SunCare
VSP Exclusive Member Extras
VSP Eyeconic Overview with Benefit Integration

Life/AD&D & Disability – MetLife

Life/Supp Life/AD&D Plan Summaries

Basic Life $25K
Basic Life $50K
Basic Life $100K
Basic Life $250K
Supplemental Life/AD&D Summary

Life/Supp Life/AD&D Forms

Life Insurance Claim Form
Statement of Health Form
Supplemental Life Enrollment Form
Portability Application Form

Life/Supp Life/AD&D Certificates

Basic Life $25K Plan Certificate
Basic Life $50K Plan Certificate
Basic Life $100K Plan Certificate
Basic Life $250K Plan Certificate
Supplemental Life $25K Plan Certificate
Supplemental Life $50K Plan Certificate
Supplemental Life $100K Plan Certificate
Supplemental Life $250K Plan Certificate

Long-Term Disability Plan Summaries

Long-term Disability Plan 1: 90 Days
Long-term Disability Plan 1: 180 Days
Long-term Disability Plan 2: 90 Days
Long-term Disability Plan 2: 180 Days
Long-term Disability Plan 3: 90 Days
Long-term Disability Plan 3: 180 Days
Long-term Disability Plan 4: 90 Days
Long-term Disability Plan 4: 180 Days

Long-Term Disability Forms

Long-term Disability – Employee Statement Claim Form
Long-term Disability – Employer Statement Claim Form
Long-term Disability – Physician Statement Claim Form

Long-Term Disability Certificates

Long-term Disability Plan 1
Long-term Disability Plan 2
Long-term Disability Plan 3
Long-term Disability Plan 4
Long-term Disability Plan 5

Short-Term Disability Plan Summaries

Short-term Disability Plan 1: 13 Weeks
Short-term Disability Plan 1: 26 Weeks
Short-term Disability Plan 2: 13 Weeks
Short-term Disability Plan 2: 26 Weeks
Short-term Disability Plan 3: 13 Weeks
Short-term Disability Plan 3: 26 Weeks
Short-term Disability Plan 4: 13 Weeks
Short-term Disability Plan 4: 26 Weeks

Short-Term Disability Forms

Short-term Disability Claim Form

Short-Term Disability Certificates

Short-term Disability Plan 1
Short-term Disability Plan 2
Short-term Disability Plan 3
Short-term Disability Plan 4

Marketing Material

MetLife Supporting Beneficiaries Overview
MetLife Grief Counseling Overview
MetLife Travel Assistance Overview
Will Preparation FAQ – For Supplemental Life Clients Only
MetLife Contacts & Resources
Portability and Conversion Overview: Understanding Your Options

Employee Assistance Program – Wellspring

Program Benefits & Marketing Material

EAP Employee Benefits Summary
EAP HR/Supervisor Benefits Summary
EAP Benefit Overview – Employee Facing
EAP Benefit Overview – HR Admin Facing

Broker Communications

View

BCBSAZ Broker Buzz: Enhance Your Business With an Innovative Association Health Plan

An affordable healthcare product bundle for your clients

BCBSAZ and Arizona Technology Council announce new Association Health Plan

Legal Notices

View

Blue Cross Blue Shield of Arizona Notice of Special Enrollment Provisions
Blue Cross Blue Shield of Arizona Notice of Privacy Practices
AZTC Summary of Plan Description (SPD)

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