HealthyBlue HMO, 2.0 and Triple Option Group and Member Applications - Virginia

Notes below are applicable to group contracts effective 4/1/04 and after:

Virginia Groups: If a group chooses BlueChoice medical coverage (HealthyBlue, 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).

HealthyBlue HMO, 2.0 and Triple Option

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment Non-Parallel Dental Only
2-50 CUT9017 N/A N/A CUT5150
(R. 3/14) (BC(HMO), BCOO(OA), HB(HMO), HB2)
GCA/LG (R. 3/14)