BlueChoice Plus / BlueChoice Plus Opt-Out - Small Group Off-SHOP Applications - Maryland

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For MD groups headquartered in Prince George's or Montgomery counties.

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment
2-50 SUM2018 (5/14) (for plans effective before 1/1/16) or

SUM3206 (9/15) (for plans effective between 1/1/16 and 12/31/16) or

SUM3459 (for plans effective 1/1/17 and after)
MD/SE/POS/GCA (1/14) (for plans effective before 1/1/16) or

MD/SE/POS/GCA (R. 1/16) (for plans effective 1/1/16 and after)
MD/SE/POE/GCA (1/14) (for plans effective before 1/1/16) or

MD/SE/POE/GCA (R. 1/16) (for plans effective 1/1/16 and after)
2-50
(BlueChoice Plus 100%/80%, $20/$30 or
BlueChoice Plus 100%/60%, $20/$30)
SUM2016 (for plans effective before 1/1/15) or

SUM2016 (5/14) (for plans effective between 1/1/15 and 12/31/15)
MD/CFBC/SE/HMO-BCOO/GCA (1/14) (for plans effective before 1/1/16) MD/SE/POE/GCA (1/14) (for plans effective before 1/1/16)
2-50
(BlueChoice Plus Opt-Out)
SUM3204 (9/15) (for plans effective between 1/1/16 and 12/31/16) or

SUM3457 (for plans effective 1/1/17 and after)
MD/CFBC/SE/HMO-BCOO/GCA (R. 1/16) (for plans effective  1/1/16 and after) MD/SE/POE/GCA (R. 1/16) (for plans effective 1/1/16 and after)

For MD groups headquartered in counties other than Prince George's and Montgomery.

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment
2-50 SUM2335 (5/14) (for plans effective before 1/1/16) or

SUM3210 (9/15) (for plans effective between 1/1/16 and 12/31/16) or

SUM3463 (for plans effective 1/1/17 and after)
CFMI/SE/POS/GCA (1/14) (for plans effective before 1/1/16) or

CFMI/SE/POS/GCA (R. 1/16) (for plans effective 1/1/16 and after)
CFMI/SE/POE/GCA (1/14) (for plans effective before 1/1/16) or

CFMI/SE/POE/GCA (R. 1/16) (for plans effective 1/1/16 and after)
2-50
(BlueChoice Plus 100%/80%, $20/$30 or
BlueChoice Plus 100%/60%, $20/$30)
SUM2016 (for plans effective before 1/1/15) or

SUM2016 (5/14) (for plans effective between 1/1/15 and 12/31/15)
MD/CFBC/SE/HMO-BCOO/GCA (1/14) (for plans effective before 1/1/16) CFMI/SE/POE/GCA (1/14) (for plans effective before 1/1/16)
2-50 (BlueChoice Plus Opt-Out) SUM3204 (9/15) (for plans effective between 1/1/16 and 12/31/16) or

SUM3457 (for plans effective 1/1/17 and after)
MD/CFBC/SE/HMO/BCOO/GCA (R. 1/16) (for plans effective 1/1/16 and after) CFMI/SE/POE/GCA (R. 1/16) (for plans effective 1/1/16 and after)

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Go to Maryland Small Group
Off-SHOP Applications and Forms

Ordering Multiple Copies:

Please contact your CareFirst Sales Representative.

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