Dental - Virginia

Freestanding Preferred (PPO), Traditional, BlueDental Plus, BlueDental EPO & BlueDental Basic

Group Size Group Subscriber Enrollment Form Group Contract Application
2-50
(Grandfathered/Non-ACA; product other than VA E&S)		 CUT5150 N/A
2-50 Freestanding
(not certified ACA benchmark plans; benefits include dental services for adults and children)
  • BlueDental Plus
  • BlueDental EPO
  • BlueDental Basic
  • Preferred Dental
  • Traditional Dental
 SUM2710

(also used for 1-50 VA groups that need to enroll in dental and/or vision benefits)

 VA/GHMSI/POE (1/13) (for plans effective prior to 5/1/19)

VA/GHMSI/DN-VS ONLY/GCA (11/18) (for plans effective 5/1/19 and after)
51+ Freestanding
(not certified ACA benchmark plans; benefits include dental services for adults and children)
  • BlueDental Plus
  • BlueDental EPO
  • BlueDental Basic
  • Preferred Dental
  • Traditional Dental
 SUM2710 VA/GHMSI/GCA/LG (1/14) (BP, HB(PPO), & DN-VS Only) (for plans effective prior to 5/1/19)

VA/GHMSI/DN-VS ONLY/GCA (11/18) (for plans effective 5/1/19 and after)