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 1-800-538-8833 for more information.
Return to Sample Policy Documents
Platinum Plans
Blue PPO Platinum Plans
Off Exchange
P503PPO Blue PPO Platinum 119
P5E1PPO Blue PPO Platinum 136
Blue Choice Preferred PPO Platinum Plans
Off Exchange
P5E2BCE Blue Choice Preferred Platinum PPO 119
P5E1BCE Blue Choice Preferred Platinum PPO 136
Blue Precision Platinum Plans
Off Exchange
P506PSN Blue Precision Platinum HMO 107
P5E1PSN Blue Precision Platinum HMO 110
BlueCare Direct Platinum Plans
Off Exchange
P506BCH BlueCare Direct Platinum 107 with Advocate
P5E1BCH BlueCare Direct Platinum 110 with Advocate
Gold Plans
Blue PPO Gold Plans
Off Exchange
G534PPO Blue PPO Gold 114
532PPO Blue PPO Gold 107
G536PPO Blue PPO Gold 116
G537PPO Blue PPO Gold 123
G531PPO Blue PPO Gold 102
G530PPO Blue PPO Gold 101
G533PPO Blue PPO Gold 113
G535PPO Blue PPO Gold 115
Blue Precision Gold HMO Plans
Off Exchange
G532PSN Blue Precision Gold HMO 101
G533PSN Blue Precision Gold HMO 109
Blue Options Gold Plans
Off Exchange
G506OPT Blue Options Gold PPO 101
G508OPT Blue Options Gold PPO 106
G507OPT Blue Options Gold PPO 102
BlueCare Direct Gold Plans
Off Exchange
G532BCH BlueCare Direct Gold 101 with Advocate
G533BCH BlueCare Direct Gold 109 with Advocate
BlueChoice Preferred Gold PPO Plans
Off Exchange
G532BCE Blue Choice Preferred Gold PPO 107
G531BCE Blue Choice Preferred Gold PPO 102
G530BCE Blue Choice Preferred Gold PPO 101
G533BCE Blue Choice Preferred Gold PPO 113
G535BCE Blue Choice Preferred Gold PPO 115
Silver Plans
Blue PPO Silver Plans
Off Exchange
S532PPO Blue PPO Silver 120
S501PPO Blue PPO Silver 135
S531PPO Blue PPO Silver 104
S535PPO Blue PPO Silver 105
S534PPO Blue PPO Silver 133
Blue Precision Silver HMO Plans
Off Exchange
S531PSN Blue Precision Silver HMO 106
S530PSN Blue Precision Silver HMO 102
BlueCare Direct Silver Plans
Off Exchange
S532BCH BlueCare Direct Silver 106 with Advocate
S530BCH BlueCare Direct Silver 102 with Advocate
BlueChoice Preferred Silver PPO Plans
Off Exchange
S532BCE Blue Choice Preferred Silver PPO 120
S501BCE Blue Choice Preferred Silver PPO 135
S531BCE Blue Choice Preferred Silver PPO 104
S535BCE Blue Choice Preferred Silver PPO 105
S534BCE Blue Choice Preferred Silver PPO 133
Blue Options Silver PPO Plans
Off Exchange
S506OPT Blue Options Silver PPO 104
S507OPT Blue Options Silver PPO 107
Bronze Plans
Blue PPO Bronze Plans
Off Exchange
B536PPO Blue PPO Bronze 132
B535PPO Blue PPO Bronze 106
BlueChoice Preferred Bronze PPO Plans
Off Exchange
B536BCE Blue Choice Preferred Bronze PPO 132
B535BCE Blue Choice Preferred Bronze PPO 106