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BluePreferred PPO - Small Group On-SHOP Applications - Virginia

BluePreferred PPO (including HSA/HRA)

Group SizeGroup Subscriber Enrollment FormGroup Contract Application
2-50 SUM4736 (for plans effective between 1/1/20 and 12/31/20)

SUM5059 (for plans effective 1/1/21 and after)
VA/GRPAPP/HCR (1/20) (HIX) (for plans effective between 1/1/20 and 12/31/20)

VA/GRPAPP/HCR (1/21) (HIX) (for plans effective 1/1/21 and after)