BlueChoice Advantage - Small Group Off-SHOP Applications - Maryland

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BlueChoice Advantage (including HSA/HRA) GHMSI

For MD groups headquartered in Prince George's or Montgomery counties.

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment
2-50


SUM7315 (for plans effective between 1/1/26 and 12/31/26)

SUM8049 (For plans effective 1/1/27 and after)

 MD/SE/POS/GCA (R. 1/19) (for plans effective 1/1/19 and after) MD/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after)

BlueChoice Advantage (including HSA/HRA) CFMI

For MD groups headquartered in counties other than Prince George's and Montgomery.

Group Size Group Subscriber Enrollment Form Group Contract Application Point of Enrollment
2-50


SUM7317 (for plans effective between 1/1/26 and 12/31/26)

SUM8051 (For plans effective 1/1/27 and after)

 CFMI/SE/POS/GCA (R. 1/19) (for plans effective 1/1/19 and after) CFMI/SE/POE/GCA (R. 1/19) (for plans effective 1/1/19 and after)

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