BluePreferred PPO - 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 SUM2019 (5/14) (for plans effective before 1/1/16) or

SUM3207 (9/15) (for plans effective between 1/1/16 and 12/31/16) or

SUM3460 (for plans effective 1/1/17 and after)
MD/CF/SE/PPO/GCA (1/14) (for plans effective before 1/1/16) or

MD/CF/SE/PPO/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)

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 SUM2332 (5/14) (for plans effective before 1/1/16) or

SUM3208 (9/15) (for plans effective between 1/1/16 and 12/31/16) or

SUM3461 (for plans effective 1/1/17 and after)
CFMI/SE/PPO/GCA (1/14) (for plans effective before 1/1/16) or

CFMI/SE/PPO/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)

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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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