CDH - BlueChoice Opt-Out Plus 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 Opt-Out Plus Open Access

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 BlueFund BlueChoice Opt-Out Plus HRA CUT5148 N/A N/A
2-50 BlueFund BlueChoice Opt-Out Plus HSA CUT5148 N/A N/A
2-50 BlueChoice Opt-Out Plus HSA or HRA Compatible Plans CUT5148 N/A N/A
2-50 BlueChoice Opt-Out Plus High Deductible Health Plans CUT5148 N/A N/A
51+ BlueFund BlueChoice Opt-Out Plus HRA CUT5148 DC/GHMSI/CFBC/POS/
GCA/LG (R. 3/14)
DC/GHMSI/CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueFund BlueChoice Opt-Out Plus HSA CUT5148 DC/GHMSI/CFBC/POS/
GCA/LG (R. 3/14)
DC/GHMSI/CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueFund BlueChoice Opt-Out Plus HSA or HRA Compatible Plans CUT5148 DC/GHMSI/CFBC/POS/
GCA/LG (R. 3/14)
DC/GHMSI/CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueChoice Opt-Out Plus High Deductible Health Plans CUT5148 DC/GHMSI/CFBC/POS/
GCA/LG (R. 3/14)
DC/GHMSI/CFBC/POE/
GCA/LG (R. 3/14)

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Applications and Forms

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