CDH - BlueChoice HMO Open Access Group and Member Forms and Applications - District of Columbia

Note: If the group is adding a BlueFund HRA at renewal or purchasing it as a new group, the group must complete the BenefitWallet HRA Set-Up Form as well as the Employer ACH Authorization.


CDH - BlueChoice HMO Open Access

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 BlueFund BlueChoice HSA CUT5154 N/A N/A
2-50 BlueChoice HSA or HRA Compatible Plans CUT5154 N/A N/A
2-50 BlueFund BlueChoice HRA CUT5154 N/A N/A
2-50 BlueChoice High Deductible Health Plans CUT5154 N/A N/A
51+ BlueChoice HSA or HRA Compatible Plans CUT5154 DC/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2) DC/GHMSI/CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueFund BlueChoice HSA CUT5154 DC/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2) DC/GHMSI/CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueFund BlueChoice HRA CUT5154 DC/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2) DC/GHMSI/CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueChoice High Deductible Health Plans CUT5154 DC/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2) DC/GHMSI/CFBC/POE/
GCA/LG (R. 3/14)

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Applications and Forms

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