BlueChoice Plus / BlueChoice Plus Opt-Out - Small Group Off-SHOP Applications - Virginia

BlueChoice Plus (including HSA/HRA) / BlueChoice Plus Opt-Out

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of Enrollment
2-50 SUM4234 (for plans effective between 1/1/19 and 12/31/19)

SUM4734 (for plans effective 1/1/20 and after)
VA/GRPAPP/HCR (1/19) (POS) VA/GRPAPP/HCR (1/19) (POE)
2-50
(BlueChoice Plus Opt-Out)
SUM4232 (for plans effective between 1/1/19 and 12/31/19)

SUM4732 (for plans effective 1/1/20 and after)
VA/GRPAPP/HCR (1/19) (HMO) VA/GRPAPP/HCR (1/19) (POE)