BlueChoice HMO and BlueChoice HMO Open Access Group and Member Applications - Virginia

Virginia Groups: If a group chooses BlueChoice medical coverage (BlueChoice, BlueChoice Opt-Out Open Access, or BlueChoice Opt-Out Plus) and indemnity dental coverage (Traditional or Preferred), and elects to offer non-parallel enrollment for dental, the group will receive a GHMSI Non-Ridered Dental contract. In this case, the group is only required to sign one Group Contract Application for the BlueChoice medical product. In this situation, the participation rules for the dental will follow the medical participation rules stated in the BlueChoice Group Contract Application. In this situation, an employee must complete two subscriber Enrollment Forms (BlueChoice & GHMSI).

BlueChoice HMO and BlueChoice HMO Open Access

Group SizeGroup Subscriber Enrollment FormGroup Contract ApplicationPoint of EnrollmentNon-Parallel Dental Only
2-50 product other than VA E&S) CUT6191 N/A N/A CUT5150
51+ (product other than VA E&S) CUT6191 VA/CFBC/GCA/LG (R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2) VA/GHMSI/
GCA/LG (R. 3/14)
VA E&S (BlueChoice HMO only) CUT5142 N/A N/A N/A