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 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
P8J6ADT Blue Advantage Platinum PPO 118
Blue Options Platinum PPO Plans
Off Exchange
P8J7OPT Blue Options Platinum PPO 311
Blue Choice Platinum PPO Plans
Off Exchange
P8J1CHC Blue Choice Platinum PPO 208
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
G8J2PFR Blue Preferred Gold PPO 418
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
G8J3ADT Blue Advantage Gold PPO 119
Blue Options Gold PPO
Off Exchange
G723OPT Blue Options Gold PPO 308
G720OPT Blue Options Gold PPO 301
G721OPT Blue Options Gold PPO 302
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
S8K1PFR Blue Preferred Silver PPO 413
S8J5PFR Blue Preferred Silver PPO 419
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
S8J4ADT Blue Advantage Silver PPO 121
S8J8ADT Blue Advantage Silver PPO 120
Blue Options Silver PPO
Off Exchange
S710OPT Blue Options Silver PPO 304
S8E1OPT Blue Options Silver PPO 310
S8J0OPT Blue Options Silver PPO
Blue Choice Silver PPO Plans
Off Exchange
S8J9CHC Blue Choice Silver PPO 209
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
Blue Advantage Bronze PPO Plans
Off Exchange
B730ADT Blue Advantage Bronze PPO 106