HealthyBlue Advantage Group and Member Applications - District of Columbia

Notes below are applicable to group contracts effective 4/1/04 and after:

DC Groups: If a group chooses BlueChoice medical coverage (HealthyBlue, BlueChoice, BlueChoice Opt-Out Open Access, or BlueChoice Opt-Out Plus) and indemnity dental coverage (Traditional or Preferred), and elects to offer non-parallel enrollment for dental, the group will receive a GHMSI Non-Ridered Dental contract. In this case, the group is only required to sign one Group Contract Application for the BlueChoice medical product. In this situation, the participation rules for the dental will follow the medical participation rules stated in the BlueChoice Group Contract Application. In this situation, an employee must complete two subscriber Enrollment Forms (BlueChoice & GHMSI).

HealthyBlue Advantage

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment Non-Parallel Dental Only
2-50 SUM1756  N/A N/A CUT5153
51+ SUM1756  DC/CFBC/GCA/
LG (R. 3/14) (BCAdv, HBAdv)
GCA/LG (R. 3/14)

Go to District of Columbia Group
Applications and Forms

Ordering Multiple Copies:

Please contact your CareFirst Sales Representative.

PDF Icon

Viewing and printing this document requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.