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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 SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 Non-MSGR SUM1984 N/A N/A
51+ SUM1984 MD/GHMSI/GCA/LG (11/18) MD/GHMSI/CFBC/POS-POE/GCA/LG (11/18)

For MD groups headquartered in counties other than Prince George's and Montgomery.

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 Non-MSGR SUM1983 N/A N/A
51+ SUM1983 CFMI/GCA/LG (11/18) CFMI/CFBC/POS-POE/GCA/LG (11/18)

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