Protect yourself from mail delivery delays. Review this Consumer Advisory from The Maryland Insurance Administration.

CDH - BlueChoice Opt-Out Plus Open Access - Group and Member Forms and Applications - Virginia

Note: If the group is adding a BlueFund HRA at renewal or purchasing it as a new group, the group must complete the HRA Plan Design Guide as well as the Employer ACH Authorization.


CDH - BlueChoice Opt-Out Plus Open Access

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 BlueFund BlueChoice Opt-Out Plus HRA (product other than VA & ES) CUT6188 N/A N/A
2-50 BlueFund BlueChoice Opt-Out Plus HSA (product other than VA & ES) CUT6188 N/A N/A
2-50 BlueChoice Opt-Out Plus HSA or HRA Compatible Plans (product other than VA & ES) CUT6188 N/A N/A
2-50 BlueChoice Opt-Out Plus High Deductible Health Plans (product other than VA & ES) CUT6188 N/A N/A
51+ BlueFund BlueChoice Opt-Out Plus HRA (product other than VA & ES) CUT6188 VA/GHMSI/
CFBC/POS/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueFund BlueChoice Opt-Out Plus HSA (product other than VA & ES) (electronic version only) CUT6188 VA/GHMSI/
CFBC/POS/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueChoice Opt-Out Plus HSA or HRA Compatible Plans (product other than VA & ES) CUT6188 VA/GHMSI/
CFBC/POS/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)
51+ BlueChoice Opt-Out Plus High Deductible Health Plans (product other than VA & ES) CUT6188 VA/GHMSI/
CFBC/POS/
GCA/LG (R. 3/14)
VA/GHMSI/
CFBC/POE/
GCA/LG (R. 3/14)