Forms and Resources for Brokers

Forms & Resources for Brokers

Selected Individual and Family Benefit Summaries:

• BlueOptimum Plus [PDF]
• BlueValue Plus [PDF]
• BlueEssential Plus [PDF]
• BluePortfolio Plus [PDF]
• Rates [PDF]

Grandfathered Individual and Family Benefit Summaries:

• BlueOptimum [PDF]
• BlueValue [PDF]
• BlueEssential [PDF]
• BluePortfolio [PDF]
• BlueSecure [PDF]
• BluePreferred Copay [PDF]
• BluePreferred Basic [PDF]
• BluePreferred Saver [PDF]
• BluePreferred Original [PDF]
• BlueSelect Plan One [PDF]
• BlueSelect Plan Two [PDF]
• BlueSelect Plan Three [PDF]
• BlueClassic [PDF]
• ExecuCare [PDF]

Group Quote Tools:

• How to Obtain a More Accurate Quote for Size 2-99 Groups [PDF]
• Request for Proposal [PDF]
• Census [PDF]
• Employee and Family Medical Questionnaire [PDF]     Español [PDF]
• Sales Compensation Information [PDF]
• Satisfaction Survey Results [PDF]
• Benefit Summaries and Benefit Comparisons

New Group Enrollment Tools:

• New Group Checklist [PDF]
• Employer Application (2-99 employees) [PDF]
• Group Certification Document [PDF]
• Sole Proprietor, Partner, or Corporate Officer Statement [PDF]
• Common Ownership Form [PDF]
• Employee Application [PDF]
• Employee and Family Medical Questionnaire [PDF]     Español [PDF]
• Welcome Guide for New Members [PDF]
• Domestic Partner Affidavit [PDF]
• Benefit Summaries and Benefit Comparisons

Existing Group Tools:

• Medical Claim Form [PDF]
• Employer Application (2-99 employees) [PDF]
• MSP Certification Document [PDF]
• Employee Application [PDF]
• Welcome Guide for New Members [PDF]
• 2010 Benefit Changes for 2-99 Groups
  • BluePreferred No Copay [PDF]
  • BluePreferred No Copay 100% [PDF]
  • BluePreferred Copay [PDF]
  • BluePreferred Copay 100% [PDF]
  • BluePreferred Basic [PDF]
  • BluePreferred Saver 100% [PDF]
  • BluePreferred Saver 80% [PDF]
  • BlueEssential [PDF]
  • BlueSelect [PDF]
  • BlueSolutions [PDF]
• Group Bulk Material Order Form
• Benefit Summaries and Benefit Comparisons
• HealthyBlue Tool Kit

  Brokers may use this brochure, presentation and sample report to introduce and highlight BCBSAZ health and wellness programs.

  • HealthyBlue Brochure [PDF]
  • HealthyBlue Presentation [PDF]
  • Sample Report: groups of 100 contracts or more [PDF]
  • Sample Report: groups of 2-99 contracts [PDF]

Privacy:

• BCBSAZ Confidential Information Release Form [PDF]      Español [PDF]
• BCBSAZ Confidential Information Release Form for HIV Related Information [PDF]
• HIPAA Notice of Privacy Practices [PDF]