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 1-866-520-2507 for more information.
Return to Sample Policy Documents
Platinum Plans
Blue Preferred Platinum PPO Plans
Off Exchange
P710PFR Blue Preferred Platinum PPO 401
P8E1PFR Blue Preferred Platinum PPO 416
Blue Advantage Platinum PPO Plans
Off Exchange
P710ADT Blue Advantage Platinum PPO 101
P8E1ADT Blue Advantage Platinum PPO 116
BlueLincs Platinum HMO Plans
Off Exchange
P8E1HMO BlueLincs Platinum HMO 004
Gold Plans
Blue Choice Gold PPO Plans
Off Exchange
G730CHC Blue Choice Gold PPO 201
G731CHC Blue Choice Gold PPO 202
G732CHC Blue Choice Gold PPO 203
Blue Preferred Gold PPO Plans
Off Exchange
G733PFR Blue Preferred Gold PPO 410
G730PFR Blue Preferred Gold PPO 402
G735PFR Blue Preferred Gold PPO 412
G731PFR Blue Preferred Gold PPO 403
Blue Advantage Gold PPO Plans
Off Exchange
G743ADT Blue Advantage Gold PPO 108
G744ADT Blue Advantage Gold PPO 109
G740ADT Blue Advantage Gold PPO 102
G746ADT Blue Advantage Gold PPO 112
G745ADT Blue Advantage Gold PPO 110
Blue Options Gold PPO
Off Exchange
G723OPT Blue Options Gold PPO 308
G720OPT Blue Options Gold PPO 301
G721OPT Blue Options Gold PPO 302
BlueLincs Gold HMO Plans
Off Exchange
G8E1HMO BlueLincs Gold HMO 011
G8E2HMO BlueLincs Gold HMO 002
G8E3HMO BlueLincs Gold HMO 008
SILVER PLANS
Blue Choice Silver PPO Plans
Off Exchange
S730CHC Blue Choice Silver PPO 204
Blue Preferred Silver PPO Plans
Off Exchange
S730PFR Blue Preferred Silver PPO 404
S731PFR Blue Preferred Silver PPO 405
S709PFR Blue Preferred Silver PPO 414
S8E1PFR Blue Preferred Silver PPO 417
S732PFR Blue Preferred Silver PPO 406
S701PFR Blue Preferred Silver PPO 415
Blue Advantage Silver PPO Plans
Off Exchange
S702ADT Blue Advantage Silver PPO 115
S730ADT Blue Advantage Silver PPO 104
S8E1ADT Blue Advantage Silver PPO 117
S731ADT Blue Advantage Silver PPO 105
Blue Options Silver PPO
Off Exchange
S710OPT Blue Options Silver PPO 304
S8E1OPT Blue Options Silver PPO 310
BlueLincs Silver HMO Plans
Off Exchange
S8E1HMO BlueLincs Silver HMO 006
S8E2HMO BlueLincs Silver HMO 001
S8E3HMO BlueLincs Silver HMO 009
B8E1HMO BlueLincs Silver HMO 005
BRONZE PLANS
Blue Choice Bronze PPO Plans
Off Exchange
B730CHC Blue Choice Bronze PPO 207
Blue Preferred Bronze PPO Plans
Off Exchange
B730PFR Blue Preferred Bronze PPO 407
B703PFR Blue Preferred Bronze PPO 413
Blue Advantage Bronze PPO Plans
Off Exchange
B730ADT Blue Advantage Bronze PPO 106
B709ADT Blue Advantage Bronze PPO 114
Blue Options Bronze PPO
Off Exchange
B710OPT Blue Options Bronze PPO 306
B711OPT Blue Options Bronze PPO 307
BlueLincs Bronze HMO Plans
Off Exchange
S8E4HMO BlueLincs Bronze HMO 003
B8E2HMO BlueLincs Bronze HMO 007
B8E3HMO BlueLincs Bronze HMO 010