CDH - BluePreferred 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 - BluePreferred
| Group Size | Group Subscriber Enrollment Form | Group Contract Application | Point of Enrollment |
|---|---|---|---|
| 2-50 BlueFund BluePreferred HRA | CUT5150 | N/A | N/A |
| 2-50 BlueFund BluePreferred HSA | CUT5150 | N/A | N/A |
| 2-50 BluePreferred HSA or HRA Compatible Plans | CUT5150 | N/A | N/A |
| 2-50 BluePreferred High Deductible Health Plans | CUT5150 | N/A | N/A |
| 51+ BlueFund BluePreferred HRA | CUT5150 | VA/GHMSI/ GCA/LG (R. 3/14) |
VA/GHMSI/ CFBC/POE/ GCA/LG (R. 3/14) |
| 51+ BlueFund BluePreferred HSA | CUT5150 | VA/GHMSI/ GCA/LG (R. 3/14) |
VA/GHMSI/ CFBC/POE/ GCA/LG (R. 3/14) |
| 51+ BluePreferred HSA or HRA Compatible Plans | CUT5150 | VA/GHMSI/ GCA/LG (R. 3/14) |
VA/GHMSI/ CFBC/POE/ GCA/LG (R. 3/14) |
| 51+ BluePreferred High Deductible Health Plans | CUT5150 | VA/GHMSI/ GCA/LG (R. 3/14) |
VA/GHMSI/ CFBC/POE/ GCA/LG (R. 3/14) |