Below is a list of actual policy documents for QHP small group coverage. These policies describe how the plans generally work and include eligible expenses, claim filing and appeals procedures, and coverage limitations and exceptions, among other things.
If you have questions, contact a customer service representative at 800-538-8833 for more information.
Return to Sample Policy Documents
Platinum Plans
Blue PPO Platinum Plans
Off Exchange
Blue Choice Preferred PPO Platinum Plans
Off Exchange
Blue Precision Platinum Plans
Off Exchange
- P506PSN Blue Precision Platinum HMO 107
- P5E1PSN Blue Precision Platinum HMO 110
- P5J1PSN Blue Precision Platinum HMO 200
Gold Plans
Blue PPO Gold Plans
Off Exchange
- G530PPO Blue PPO Gold 101
- G531PPO Blue PPO Gold 102
- G532PPO Blue PPO Gold 107
- G533PPO Blue PPO Gold 113
- G534PPO Blue PPO Gold 114
- G535PPO Blue PPO Gold 115
- G536PPO Blue PPO Gold 116
- G537PPO Blue PPO Gold 123
Blue Precision Gold HMO Plans
Off Exchange
Blue Options Gold Plans
Off Exchange
- G506OPT Blue Options Gold PPO 101
- G507OPT Blue Options Gold PPO 102
- G508OPT Blue Options Gold PPO 106
- G5K1OPT Blue Options Gold PPO 200
BlueChoice Preferred Gold PPO Plans
Off Exchange
- G530BCE Blue Choice Preferred Gold PPO 101
- G531BCE Blue Choice Preferred Gold PPO 102
- G532BCE Blue Choice Preferred Gold PPO 107
- G533BCE Blue Choice Preferred Gold PPO 113
- G535BCE Blue Choice Preferred Gold PPO 115
Silver Plans
Blue PPO Silver Plans
Off Exchange
- S531PPO Blue PPO Silver 104
- S535PPO Blue PPO Silver 105
- S532PPO Blue PPO Silver 120
- S534PPO Blue PPO Silver 133
- S5J1PPO Blue PPO Silver 200
Blue Precision Silver HMO Plans
Off Exchange
BlueChoice Preferred Silver PPO Plans
Off Exchange
- S531BCE Blue Choice Preferred Silver PPO 104
- S535BCE Blue Choice Preferred Silver PPO 105
- S532BCE Blue Choice Preferred Silver PPO 120
- S534BCE Blue Choice Preferred Silver PPO 133
- S5J1BCE Blue Choice Preferred Silver PPO 200