Medicare Supplement Plan

  • How to Complete Your Out-of-Network Claim Form (Senior Preferred members)
    Medical Claim
    Dental Claim
    BlueDental Prevention +1 Submission Form
    Pharmacy Claim
    Pharmacy Compounded Medication Claim
  • Autopay Authorization
  • Medicare Supplement Application
  • Attestation Form (Effective 04/01/2025)
    Attestation Form (Effective 04/01/2024)
  • Confidential Information Release Form
    Confidential Information Release for HIV Form
    Accounting of PHI Disclosure Request Form
    Amendment to PHI Disclosure Request Form
    Appointment of Representatives Form
    Request for Protect Communications Form
    Request for Health Records Form
    Privacy Complaint Form
    HIPAA Notice of Privacy Practices
    Blue Cross® Blue Shield® of Arizona (AZ Blue) is contracted with Medicare to offer HMO Medicare Advantage plans. Enrollment in AZ Blue plans depends on contract renewal.

    You are eligible to enroll in a AZ Blue Medicare Supplement plan if you are age 65 or older, entitled to Medicare Part A, and enrolled in Medicare Part B, and you live in the plan service area. You must continue to pay your Medicare Part B premiums (and Part A, if applicable), if not otherwise paid for by Medicaid or another third party. During the first six months when you are age 65 and also enrolled in Medicare Parts A & B you cannot be denied a Medicare Supplement plan when you apply for one, regardless of health status.

    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.
    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.

    OptumRx® is an independent company providing prescription mail order services.

    AZBLUE SEN 08 09/24
    Y0137_M40278PY25_M
    Last Updated 01/01/2025