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Dental - Maryland

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Freestanding Preferred (PPO), Traditional, BlueDental Plus & BlueDental Basic GHMSI

For MD groups headquartered in Prince George's or Montgomery counties.

Group Size Group Subscriber Enrollment Form Group Contract Application
2-50 MSGR
(Grandfathered/Non-ACA)		 SUM1038 N/A
2-50 Freestanding
(ACA-compliant member level rated plans)

  • - BlueDental Preferred
    - BlueDental Traditional

 SUM2029 MD/CF/SG/DENT-VIS/GCA (1/16) (for plans effective before 1/1/17) or MD/GHMSI/SG/DENT-VIS/GCA (1/17) (for plans effective 1/1/17 and after)
2-50 & 51+ Freestanding
(not certified ACA benchmark plans; benefits include dental services for adults and children)

  • - BlueDental Plus
    - BlueDental Basic
    - Preferred Dental
    - Traditional Dental

 SUM2711 MD/GHMSI DN-VS ONLY GRP APP (R. 1/13) (MD GHMSI DN-VS ONLY 10/16)

Freestanding Preferred (PPO), Traditional, BlueDental Plus & BlueDental Basic CFMI

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

Group Size Group Subscriber Enrollment Form Group Contract Application
2-50 MSGR
(Grandfathered/Non-ACA)		 SUM1037 N/A
2-50 Freestanding
(ACA-compliant member level rated plans)

  • - BlueDental Preferred
    - BlueDental Traditional

 SUM2029 CFMI/SG/DENT-VIS/GCA (1/16) (for plans effective before 1/1/17) or CFMI/SG/DENT-VIS/GCA (1/17) (for plans effective 1/1/17 and after)

 
2-50 & 51+ Freestanding
(not certified ACA benchmark plans; benefits include dental services for adults and children)

  • - BlueDental Plus
    - BlueDental Basic
    - Preferred Dental
    - Traditional Dental

 SUM2711 CFMI/DN-VS ONLY GCA (R. 1/13) (CFMI DN-VS ONLY 10/16)

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Go to Maryland Group Applications
and Forms

Ordering Multiple Copies:

Please contact your CareFirst Sales Representative.

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