BluePreferred - Group and Member Applications - Maryland

Non-MSGR MD Groups: If a group chooses BlueChoice medical coverage (HealthyBlue, BlueChoice, BlueChoice Open Access, BlueChoice Opt-Out Open Access, or BlueChoice Opt-Out Plus Open Access ) and indemnity dental coverage (Traditional or Preferred), and elects to offer non-parallel enrollment for dental, the group will receive a GHMSI or CFMI Non-Ridered Dental contract. In this case, the group is required to sign two Group Contract Applications (BlueChoice & GHMSI or CFMI), unless the group selects a Point-of-Enrollment package, which only requires the signed Point-of-Enrollment Group Contract Application. In this situation, an employee must complete two subscriber Enrollment Forms (BlueChoice & GHMSI or CFMI).

MSGR MD Groups: If a group chooses BlueChoice medical coverage (HealthyBlue, BlueChoice, BlueChoice Open Access, BlueChoice Opt-Out Open Access, or BlueChoice Opt-Out Plus Open Access ) and indemnity dental coverage (Traditional or Preferred), and elects to offer non-parallel enrollment for dental, the group will receive a GHMSI or CFMI Non-Ridered Dental contract. In this case, the group is required to sign two Group Contract Applications (BlueChoice & GHMSI or CFMI) and an employee must complete two subscriber Enrollment Forms (BlueChoice & GHMSI or CFMI).

Note: MSGR BluePreferred/SPPP Plans that elect to cover Retirees and offer non-parallel (non-rider) Traditional/Preferred Dental and/or BlueVision Plus must complete two (2) CFMI or GHMSI Group Applications - (1) BluePreferred  Group Application, and (1) Dental/Vision Non-Parallel Enrollment Group Application. (Retirees are only allowed to enroll in an ancillary plan if they are enrolling in BluePreferred medical.)


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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) SUM1038 N/A
MSGR (Renewing SELF-EMPLOYED) N/A 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) SUM1037 N/A
MSGR (Renewing SELF-EMPLOYED) N/A 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 CUT5141 N/A N/A
51+ CUT5141 MD/GHMSI/GCA/LG (1/14) MD/GHNSI/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 CUT8514 N/A N/A
51+ CUT8514 CFMI/GCA/LG (1/14) CFMI/CFBC/POE/GCA/LG (1/14)

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