CDH - BluePreferred 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 - BluePreferred

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment
2-50 BlueFund BluePreferred HRA CUT5150 N/A N/A
2-50 BlueFund BluePreferred HSA CUT5150 N/A N/A
2-50 BluePreferred HSA or HRA Compatible Plans CUT5150 N/A N/A
2-50 BluePreferred High Deductible Health Plans CUT5150 N/A N/A
51+ BlueFund BluePreferred HRA CUT5150 VA/GHMSI/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueFund BluePreferred HSA CUT5150 VA/GHMSI/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BluePreferred HSA or HRA Compatible Plans CUT5150 VA/GHMSI/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BluePreferred High Deductible Health Plans CUT5150 VA/GHMSI/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)

Go to Virginia Group Applications and Forms

Ordering Multiple Copies:

Please contact your CareFirst Sales Representative.

PDF Icon

Viewing and printing this document requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.