BlueFund CDH - BluePreferred - Group and Member Forms and Applications - Maryland

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.


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

Group Size
Group Subscriber Enrollment Form Group Contract Application
MSGR (2-50) BlueFund BluePreferred HSA SUM1038 N/A
MSGR (2-50) BluePreferred HSA Compatible and HRA Compatible and BlueFund Plans SUM1038 N/A
MSGR (2-50) BluePreferred High Deductible Health Plans SUM1038 N/A

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

Group Size Group Subscriber Enrollment Form Group Contract Application
MSGR (2-50) BlueFund BluePreferred HSA SUM1037 N/A
MSGR (2-50) BluePreferred HSA Compatible and HRA Compatible and BlueFund Plans SUM1037 N/A
MSGR (2-50) BluePreferred High Deductible Health Plans SUM1037 N/A

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 NON-MSGR BlueFund BluePreferred HRA CUT5141 N/A N/A
2-50 NON-MSGR BlueFund BluePreferred HSA CUT5141 N/A N/A
2-50 NON-MSGR BluePreferred HSA or HRA Compatible Plans CUT5141 N/A N/A
2-50 NON-MSGR BluePreferred High Deductible Health Plans CUT5141 N/A N/A
51+ BlueFund BluePreferred HRA CUT5141 MD/GHMSI/GCA/LG (1/14) MD/GHMSI/
CFBC/POE/
GCA/LG (1/14)
51+ BlueFund BluePreferred HSA CUT5141 MD/GHMSI/GCA/LG (1/14) MD/GHMSI/
CFBC/POE/
GCA/LG (1/14)
51+ BluePreferred HSA or HRA Compatible Plans CUT5141 MD/GHMSI/GCA/LG (1/14) MD/GHMSI/
CFBC/POE/
GCA/LG (1/14)
51+ BluePreferred High Deductible Health Plans CUT5141 MD/GHMSI/GCA/LG (1/14) MD/GHMSI/
CFBC/POE/
GCA/LG (1/14)

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 NON-MSGR BlueFund BluePreferred HRA CUT8514 N/A N/A
2-50 NON-MSGR BlueFund BluePreferred HSA CUT8514 N/A N/A
2-50 NON-MSGR BlueFund BluePreferred HSA or HRA Compatible Plans CUT8514 N/A N/A
2-50 NON-MSGR BlueFund BluePreferred High Deductible Health Plans CUT8514 N/A N/A
51+ BlueFund BluePreferred HRA CUT8514 CFMI/GCA/LG (1/14) CFMI/CFBC/
POE/GCA/
LG (1/14)
51+ BlueFund BluePreferred HSA CUT8514 CFMI/GCA/LG (1/14) CFMI/CFBC/
POE/GCA/
LG (1/14)
51+ BlueFund BluePreferred HSA or HRA Compatible Plans CUT8514 CFMI/GCA/LG (1/14) CFMI/CFBC/
POE/GCA/
LG (1/14)
51+ BluePreferred High Deductible Health Plans CUT8514 CFMI/GCA/LG (1/14) CFMI/CFBC/
POE/GCA/
LG (1/14)

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and Forms

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