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

BlueChoice Plus (including HSA/HRA) / BlueChoice Plus Opt-Out

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment
2-50 SUM2026 (5/14) (for plans effective before 1/1/16) or

SUM2874 (for plans effective between 1/1/16 and 12/31/16) or

SUM3448 (for plans effective 1/1/17 and after)
VA/GRPAPP/HCR (1/14) (POS) VA/GRPAPP/HCR (1/14) (POE)
2-50
(BlueChoice Plus 100%/80%, $20/$30 or
BlueChoice Plus 100%/60%, $20/$30)
SUM2024 (for plans effective before 1/1/15) or

SUM2024 (5/14) (for plans effective between 1/1/15 and 12/31/15)
VA/GRPAPP/HCR (1/14) (HMO) VA/GRPAPP/HCR (1/14) (POE)
2-50
(BlueChoice Plus Opt-Out)
SUM2872 (for plans effective between 1/1/16 and 12/31/16) or

SUM3446 (for plans effective 1/1/17 and after)
VA/GRPAPP/HCR (1/14) (HMO) VA/GRPAPP/HCR (1/14) (POE)

Go to Virginia Small Group Off-SHOP Applications and Forms

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