Forms & Information

Maricopa-Pinal Counties

My Plan and Coverage Information

Summary of Benefits
Provides a summary of payment and coverage information

Evidence of Coverage
Contains a full breakdown of payment and coverage information
Request a hard copy of an EOC
Annual Notice of Changes
Details specific changes made to plan at the start of each plan year

Directories

Requesting a Person to Represent Me or Have Access to My Confidential

Appointing a Representative - You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
Nombramiento de un Representante

Use the Plan's Coverage for your Medical Services

Out-of-Network Coverage Rules - How to get care from out-of-network providers or pharmacies.

Enrollment Forms

Payment Forms

Direct Member Reimbursement Form

Direct Member Reimbursement Form-Request reimbursement for covered medical care and supplies that were paid out-of-pocket.

Pima County

My Plan and Coverage Information

Summary of Benefits
Provides a summary of payment and coverage information

Evidence of Coverage
Contains a full breakdown of payment and coverage information
Request a hard copy of an EOC
- Classic Evidence of Coverage (EOC)
- Evidencia de cobertura Classic (EOC)
Annual Notice of Changes
Details specific changes made to plan at the start of each plan year

Directories

Requesting a Person to Represent Me or Have Access to My Confidential

Appointing a Representative - You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
Nombramiento de un Representante

Use the Plan's Coverage for your Medical Services

Out-of-Network Coverage Rules - How to get care from out-of-network providers or pharmacies.

Enrollment Forms

Payment Forms

Direct Member Reimbursement Form

Direct Member Reimbursement Form-Request reimbursement for covered medical care and supplies that were paid out-of-pocket.

Santa Cruz County

My Plan and Coverage Information

Summary of Benefits
Provides a summary of payment and coverage information

Evidence of Coverage
Contains a full breakdown of payment and coverage information
Request a hard copy of an EOC
- Standard Evidence of Coverage (EOC)
- Evidencia de cobertura Standard (EOC)
Annual Notice of Changes
Details specific changes made to plan at the start of each plan year

Directories

Requesting a Person to Represent Me or Have Access to My Confidential Information

Appointing a Representative - You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
Nombramiento de un Representante

Use the Plan's Coverage for your Medical Services

Out-of-Network Coverage Rules - How to get care from out-of-network providers or pharmacies.

Enrollment Forms

Payment Forms

Direct Member Reimbursement Form

Direct Member Reimbursement Form-Request reimbursement for covered medical care and supplies that were paid out-of-pocket.

Blue Cross® Blue Shield® of Arizona (BCBSAZ) is contracted with Medicare to offer HMO and PPO Medicare Advantage plans and PDP plans.
Enrollment in BCBSAZ plans depends on contract renewal.

Member Services can be reached at 480-937-0409 (in Arizona) or at our toll-free phone number at 1-800-446-8331 (TTY users should call 711). Hours are 8 a.m. to 8 p.m., Monday through Friday from April 1 to September 30; and 7 days a week from October 1 to March 31. Member Services also has free language interpreter services available for non-English speakers

Health Choice Pathway HMO D-SNP is a Health Plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Health Choice Pathway HMO D-SNP depends on contract renewal. Health Choice Pathway Member Services can be reached at 1-800-656-8991, TTY: 711, 8 a.m. to 8 p.m., 7 days a week.

Blue Cross Blue Shield of Arizona (BCBSAZ) and Health Choice Arizona (HCA) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We provide free aids and services to people with disabilities to communicate effectively with us, such as qualified interpreters and written information in other formats such as large print and accessible electronic formats. We also provide free language services to people whose primary language is not English, such as qualified interpreters and written information in other languages. If you need these services call 1-800-446-8331 (TTY: 711) for BCBSAZ or 1-800-656-8991 (TTY: 711) for HCA.

Spanish (BCBSAZ): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-446-8331 (TTY: 711).

Navajo (BCBSAZ): Díí baa akó nínízin: Díí saad bee yάnílti’ go Diné Bizaad, saad bee άkά’ άnída’ άwo’ dę͗ę͗, t’άά jiik’eh, éí nά hóló̖, kojí̖ hódíílnih 1-800-446-8331 (TTY: 711).

Spanish (HCA): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-656-8991 (TTY: 711).

Navajo (HCA): Díí baa akó nínízin: Díí saad bee yάnílti’ go Diné Bizaad, saad bee άkά’ άnída’ άwo’ dę͗ę͗, t’άά jiik’eh, éí nά hóló̖, kojí̖ hódíílnih 1-800-656-8991 (TTY: 711).

© Blue Cross Blue Shield of Arizona. An independent licensee of the Blue Cross and Blue Shield Association

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Last Updated: June 25, 2022