Traditional - NCA Products Only - Group & 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 (BlueChoice, BlueChoice Opt-Out, 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).

Traditional - NCA Products Only

Group Size Group Subscriber Enrollment Form
2-24 (product other than VA E & S) CUT5152
25+ (product other than VA E & S) CUT5150
VA E & S CUT6197