CDH - BlueChoice HMO Open Access - Virginia

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.


CDH - BlueChoice HMO Open Access

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment
2-50 BlueFund BlueChoice HSA (product other than VA & ES) CUT6191 N/A N/A
2-50 BlueChoice HSA or HRA Compatible Plans (product other than VA & ES) CUT6191 N/A N/A
2-50 BlueFund BlueChoice HRA (product other than VA & ES) CUT6191 N/A N/A
2-50 BlueChoice High Deductible Health Plans (product other than VA & ES) CUT6191 N/A N/A
51+ BlueFund BlueChoice HSA (product other than VA & ES) CUT6191 VA/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2) VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueChoice HSA or HRA Compatible Plans (product other than VA & ES) CUT6191 VA/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2) VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueFund BlueChoice HRA (product other than VA & ES) CUT6191 VA/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2) VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueChoice High Deductible Health Plans (product other than VA & ES) CUT6191 VA/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2) VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)

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