HealthyBlue PPO - 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).


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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 Non-MSGR SUM1984 N/A N/A
51+ SUM1984 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 SUM1983 N/A N/A
51+ SUM1983 CFMI/GCA/LG (1/14) CFMI/CFBC/POE/GCA/LG (1/14)

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Go to Maryland Group Applications
and Forms

Ordering Multiple Copies:

Please contact your CareFirst Sales Representative.

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