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
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
- P8K1ADT Blue Advantage Platinum PPO 122
Blue Options Platinum PPO Plans
Off Exchange
Blue Choice Platinum PPO Plans
Off Exchange
Gold Plans
Blue Choice Gold PPO Plans
Off Exchange
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
- P8K4PFR Blue Preferred Platinum PPO 420
- P8K1PFR Blue Preferred Platinum PPO 421
- G8K2PFR Blue Preferred Gold PPO 422
- G8K5PFR Blue Preferred Gold PPO 423
- G8K3PFR Blue Preferred Gold PPO 424
- G8K4PFR Blue Preferred Gold PPO 425
- G8K6PFR Blue Preferred Gold PPO 426
- GG8K7PFR Blue Preferred Gold PPO 431
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
- G8K2ADT Blue Advantage Gold PPO 123
- G8K3ADT Blue Advantage Gold PPO 124
- G8K4ADT Blue Advantage Gold PPO 125
- G8K6ADT Blue Advantage Gold PPO 126
- G8K7ADT Blue Advantage Gold PPO 132
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
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
- S8K9PFR Blue Preferred Silver PPO 427
- S8K0PFR Blue Preferred Silver PPO 429
- S8K5PFR Blue Preferred Silver PPO 430
- S8L1PFR Blue Preferred Silver PPO 432
- S8K8PFR Blue Preferred Silver PPO 433
Blue Advantage Silver PPO Plans
Off Exchange
- S8K1ADT Blue Advantage Silver PPO 114
- 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
- S8L1ADT Blue Advantage Silver PPO 127
- S8K2ADT Blue Advantage Silver PPO 128
- S8K9ADT Blue Advantage Silver PPO 129
- S8K5ADT Blue Advantage Silver PPO 131
- S8K3ADT Blue Advantage Silver PPO 133
- S8K8ADT Blue Advantage Silver PPO 134
Blue Options Silver PPO
Off Exchange
- S710OPT Blue Options Silver PPO 304
- S8E1OPT Blue Options Silver PPO 310
- S8J0OPT Blue Options Silver PPO 312