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
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Blue Preferred Platinum EPO Plans
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P821PFR Blue Preferred Platinum EPO 128
P820PFR Blue Preferred Platinum EPO 127
Blue Advantage Platinum HMO Plans
P7J4ADT Blue Advantage Platinum HMO 210
Gold Plans
Blue PPO Gold Plans
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Blue HMO Network Gold Plans
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G7E1HMO Blue HMO Network Gold 204
G7E3HMO Blue HMO Network Gold 205
G7J3HMO Blue HMO Network Gold 101
Blue Advantage Gold Plans
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G7E1ADT Blue Advantage Gold HMO 207
G7J5ADT Blue Advantage Gold HMO 209
Blue Preferred EPO Gold Plans
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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
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Blue Preferred Silver EPO
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S7E1PFR Blue Preferred Silver EPO 135
S842PFR Blue Preferred Silver EPO 131
S7E5PFR Blue Preferred Silver EPO 136
S840PFR Blue Preferred Silver EPO 125
S7J2PFR Blue Preferred Silver EPO 101
Blue HMO Network Silver Plans
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S810HMO Blue HMO Network Silver 202
Blue Advantage Silver Plans
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S7E3ADT Blue Advantage Silver HMO 208
Bronze Plans
Blue PPO Bronze Plans
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Blue Preferred Bronze EPO Plans
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