CDH - BlueChoice Opt-Out Plus Open Access - Group and Member Forms and Applications - 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 Opt-Out Plus Open Access

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment
2-50 BlueFund BlueChoice Opt-Out Plus HRA (product other than VA & ES) CUT6188 N/A N/A
2-50 BlueFund BlueChoice Opt-Out Plus HSA (product other than VA & ES) CUT6188 N/A N/A
2-50 BlueChoice Opt-Out Plus HSA or HRA Compatible Plans (product other than VA & ES) CUT6188 N/A N/A
2-50 BlueChoice Opt-Out Plus High Deductible Health Plans (product other than VA & ES) CUT6188 N/A N/A
51+ BlueFund BlueChoice Opt-Out Plus HRA (product other than VA & ES) CUT6188 VA/GHMSI/
CFBC/POS/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueFund BlueChoice Opt-Out Plus HSA (product other than VA & ES) (electronic version only) CUT6188 VA/GHMSI/
CFBC/POS/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueChoice Opt-Out Plus HSA or HRA Compatible Plans (product other than VA & ES) CUT6188 VA/GHMSI/
CFBC/POS/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueChoice Opt-Out Plus High Deductible Health Plans (product other than VA & ES) CUT6188 VA/GHMSI/
CFBC/POS/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)

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