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BluePreferred PPO - Small Group Off-SHOP Applications - Maryland

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	SUM7318 (for plans effective between 1/1/26 and 12/31/26) SUM8052 (For plans effective 1/1/27 and after)	MD/CF/SE/PPO/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)

Group Size

Group Subscriber Enrollment Form

Group Contract Application

Point of Enrollment

2-50

SUM7318 (for plans effective between 1/1/26 and 12/31/26)

SUM8052 (For plans effective 1/1/27 and after)

MD/CF/SE/PPO/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)

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	SUM7316 (for plans effective between 1/1/26 and 12/31/26) SUM8050 (For plans effective 1/1/27 and after)	CFMI/SE/PPO/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)

Group Size

Group Subscriber Enrollment Form

Group Contract Application

Point of Enrollment

2-50

SUM7316 (for plans effective between 1/1/26 and 12/31/26)

SUM8050 (For plans effective 1/1/27 and after)

CFMI/SE/PPO/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)