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 the number provided on the back of your ID card for more information.
Return to Sample Policy Documents
Platinum Plans
Blue PPO Platinum Plans
Off Exchange
P811PPO Blue PPO Platinum 111
P810PPO Blue PPO Platinum 110
Blue Preferred Platinum EPO Plans
Off Exchange
P821PFR Blue Preferred Platinum EPO 128
P820PFR Blue Preferred Platinum EPO 127
Gold Plans
Blue PPO Gold Plans
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G822PPO Blue PPO Gold 104
G7E1PPO Blue PPO Gold 114
G820PPO Blue PPO Gold 102
G821PPO Blue PPO Gold 103
G823PPO Blue PPO Gold 107
G7E3PPO Blue PPO Gold 115
Blue HMO Network Gold Plans
Off Exchange
G7E1HMO Blue HMO Network Gold 204
G7E3HMO Blue HMO Network Gold 205
Blue Advantage Gold Plans
Off Exchange
G7E1ADT Blue Advantage Gold HMO 207
Blue Preferred EPO Gold Plans
Off Exchange
G802PFR Blue Preferred Gold EPO 930
G832PFR Blue Preferred Gold EPO 122
G833PFR Blue Preferred Gold EPO 123
G836PFR Blue Preferred Gold EPO 130
G7E1PFR Blue Preferred Gold EPO 137
G801PFR Blue Preferred Gold EPO 208
G835PFR Blue Preferred Gold EPO 129
Silver Plans
Blue PPO Silver Plans
Off Exchange
S830PPO Blue PPO Silver 105
S7E4PPO Blue PPO Silver 116
S831PPO Blue PPO Silver 106
S7E7PPO Blue PPO Silver 117
S833PPO Blue PPO Silver 108
S7F1PPO Blue PPO Silver 118
Blue Preferred Silver EPO
Off Exchange
S7E1PFR Blue Preferred Silver EPO 135
S842PFR Blue Preferred Silver EPO 131
S7E5PFR Blue Preferred Silver EPO 136
S840PFR Blue Preferred Silver EPO 125
Blue HMO Network Silver Plans
Off Exchange
S810HMO Blue HMO Network Silver 202
Blue Advantage Silver Plans
Off Exchange
S7E3ADT Blue Advantage Silver HMO 208
Bronze Plans
Blue PPO Bronze Plans
Off Exchange
B830PPO Blue PPO Bronze 101
B831PPO Blue PPO Bronze 109