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BluePreferred PPO - Small Group Off-SHOP Applications - Virginia

BluePreferred PPO (including HSA/HRA)

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 SUM4735 (for plans effective between 1/1/20 and 12/31/20)

SUM5065 (for plans effective 1/1/21 and after)
VA/GRPAPP/HCR (1/19) (PPO) VA/GRPAPP/HCR (1/19) (POE)