BluePreferred PPO - Small Group On-SHOP Applications - Virginia

BluePreferred PPO (including HSA/HRA)

Group Size Group Subscriber Enrollment Form Group Contract Application
2-50 SUM6125 (for plans effective 1/1/21 and 12/31/23)

SUM6617 (for plans effective 1/1/24 and after)
VA/GRPAPP/HCR (1/21) (HIX) (for plans effective 1/1/21 and 12/31/23)

VAGRPAPP-HCR (R. 1-24) (for plans effective 1/1/24 and after)