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 888-697-0683 for more information.
Return to Sample Policy Documents
Platinum Plans
Blue Choice Advantage Platinum PPO Plans
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Policy Books
- P9K3CHC Blue Choice Platinum PPO 202
- P9K4CHC Blue Choice Platinum PPO 202 – in vitro
- P9M1CHC Blue Choice Platinum PPO 301
- P9M2CHC Blue Choice Platinum PPO 301-in vitro
- P620CHC Blue Choice Platinum PPO 810
- PV20CHC Blue Choice Platinum PPO 810-in vitro
- P621CHC Blue Choice Platinum PPO 811
- PV21CHC Blue Choice Platinum PPO 811-in vitro
Blue Advantage Platinum HMO Plans
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Policy Books
- P9K3ADT Blue Advantage Platinum HMO 202
- P9K4ADT Blue Advantage Platinum HMO 202 – in vitro
- P9M1ADT Blue Advantage Platinum HMO 301
- P9M2ADT Blue Advantage Platinum HMO 301-in vitro
- P610ADT Blue Advantage Platinum HMO 807
- PV10ADT Blue Advantage Platinum HMO 807-in vitro
- P611ADT Blue Advantage Platinum HMO 808
- PV11ADT Blue Advantage Platinum HMO 808-in vitro
Plan Descriptions
- P9K3ADT Blue Advantage Platinum HMO 202
- P9K4ADT Blue Advantage Platinum HMO 202 – in vitro
- P9M1ADT Blue Advantage Platinum HMO 301
- P9M2ADT Blue Advantage Platinum HMO 301-in vitro
- P610ADT Blue Advantage Platinum HMO 807
- PV10ADT Blue Advantage Platinum HMO 807-in vitro
- P611ADT Blue Advantage Platinum HMO 808
- PV11ADT Blue Advantage Platinum HMO 808-in vitro
Gold Plans
Blue Choice Gold PPO Plans
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Policy Books
- G9K4CHC Blue Choice Gold PPO 103
- G9K5CHC Blue Choice Gold PPO 103-in-vitro
- G9K6CHC Blue Choice Gold PPO 112
- G9K7CHC Blue Choice Gold PPO 112-in-vitro
- G9K8CHC Blue Choice Gold PPO 114
- G9K9CHC Blue Choice Gold PPO 114-in-vitro
- G9L1CHC Blue Choice Gold PPO 117
- G9L2CHC Blue Choice Gold PPO 117-in-vitro
- G9L5CHC Blue Choice Gold PPO 203
- G9L6CHC Blue Choice Gold PPO 203 - in vitro
- G9L7CHC Blue Choice Gold PPO 204
- G9L7CHC Blue Choice Gold PPO 204 -in vitro
- G650CHC Blue Choice Gold PPO 801
- GV50CHC Blue Choice Gold PPO 801-in vitro
- G651CHC Blue Choice Gold PPO 819
- GV51CHC Blue Choice Gold PPO 819-in vitro
- G652CHC Blue Choice Gold PPO 820
- GV52CHC Blue Choice Gold PPO 820-in vitro
- G653CHC Blue Choice Gold PPO 822
- GV53CHC Blue Choice Gold PPO 822-in vitro
- G654CHC Blue Choice Gold PPO 823
- GV54CHC Blue Choice Gold PPO 823-in vitro
- G656CHC Blue Choice Gold PPO 830
- GV56CHC Blue Choice Gold PPO 830-in vitro
Blue Advantage Gold HMO Plans
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Policy Books
- G9J1ADT Blue Advantage Gold HMO 103
- G9J2ADT Blue Advantage Gold HMO 103-in vitro
- G9K5ADT Blue Advantage Gold HMO 203
- G9K6ADT Blue Advantage Gold HMO 203 -in vitro
- G9K7ADT Blue Advantage Gold HMO 204
- G9K8ADT Blue Advantage Gold HMO 204 -in vitro
- G660ADT Blue Advantage Gold HMO 801
- GV60ADT Blue Advantage Gold HMO 801-in vitro
- G661ADT Blue Advantage Gold HMO 812
- GV61ADT Blue Advantage Gold HMO 812-in vitro
- G662ADT Blue Advantage Gold HMO 814
- GV62ADT Blue Advantage Gold HMO 814-in vitro
- G663ADT Blue Advantage Gold HMO 816
- GV63ADT Blue Advantage Gold HMO 816-in vitro
- G664ADT Blue Advantage Gold HMO 817
- GV64ADT Blue Advantage Gold HMO 817-in vitro
- G665ADT Blue Advantage Gold HMO 822
- GV65ADT Blue Advantage Gold HMO 822-in vitro
- G666ADT Blue Advantage Gold HMO 830
- GV66ADT Blue Advantage Gold HMO 830-in vitro
- G9E2ADT Blue Advantage Gold HMO 919
- G9E1ADT Blue Advantage Gold HMO 919-in vitro
- G9E3ADT Blue Advantage Gold HMO 922
- G9E4ADT Blue Advantage Gold HMO 922-in vitro
- G9E5ADT Blue Advantage Gold HMO 923
- G9E6ADT Blue Advantage Gold HMO 923-in vitro
Plan Descriptions
- G660ADT Blue Advantage Gold HMO 801
- GV60ADT Blue Advantage Gold HMO 801-in vitro
- G661ADT Blue Advantage Gold HMO 812
- GV61ADT Blue Advantage Gold HMO 812-in vitro
- G662ADT Blue Advantage Gold HMO 814
- GV62ADT Blue Advantage Gold HMO 814-in vitro
- G663ADT Blue Advantage Gold HMO 816
- GV63ADT Blue Advantage Gold HMO 816-in vitro
- G664ADT Blue Advantage Gold HMO 817
- GV64ADT Blue Advantage Gold HMO 817-in vitro
- G665ADT Blue Advantage Gold HMO 822
- GV65ADT Blue Advantage Gold HMO 822-in vitro
- G666ADT Blue Advantage Gold HMO 830
- GV66ADT Blue Advantage Gold HMO 830-in vitro
- G9E1ADT Blue Advantage Gold HMO 919
- G9E2ADT Blue Advantage Gold HMO 919-in vitro
- G9E3ADT Blue Advantage Gold HMO 922
- G9E4ADT Blue Advantage Gold HMO 922-in vitro
- G9E5ADT Blue Advantage Gold HMO 923
- G9E6ADT Blue Advantage Gold HMO 923-in vitro
Silver Plans
Blue Choice Silver PPO Plans
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Policy Books
- S9L3CHC Blue Choice Silver PPO 101
- S9L4CHC Blue Choice Silver PPO 101-in-vitro
- S9L5CHC Blue Choice Silver PPO 102
- S9L6CHC Blue Choice Silver PPO 102-in-vitro
- S9L9CHC Blue Choice Silver PPO 118
- S9M1CHC Blue Choice Silver PPO 118-in-vitro
- S9M4CHC Blue Choice Silver PPO 120
- S9M5CHC Blue Choice Silver PPO 120-in vitro
- S9M2CHC Blue Choice Silver PPO 135
- S9M3CHC Blue Choice Silver PPO 135-in-vitro
- S9L7CHC Blue Choice Silver PPO 146
- S9L8CHC Blue Choice Silver PPO 146-in-vitro
- S9K1CHC Blue Choice Silver PPO 201
- S9K2CHC Blue Choice Silver PPO 201 – in vitro
- S9N1CHC Blue Choice Silver PPO 401
- S9N2CHC Blue Choice Silver PPO 401 – in-vitro
- S9N3CHC Blue Choice Silver PPO 402
- S9N4CHC Blue Choice Silver PPO 402 – in vitro
- S660CHC Blue Choice Silver PPO 803
- SV60CHC Blue Choice Silver PPO 803-in vitro
- S661CHC Blue Choice Silver PPO 824
- SV61CHC Blue Choice Silver PPO 824-in vitro
- S662CHC Blue Choice Silver PPO 825
- SV62CHC Blue Choice Silver PPO 825-in vitro
- S663CHC Blue Choice Silver PPO 827
- SV63CHC Blue Choice Silver PPO 827-in vitro
- S665CHC Blue Choice Silver PPO 834
- SV65CHC Blue Choice Silver PPO 834-in vitro
- S666CHC Blue Choice Silver PPO 844
- SV66CHC Blue Choice Silver PPO 844-in vitro
- S667CHC Blue Choice Silver PPO 845
- SV67CHC Blue Choice Silver PPO 845-in vitro
Blue Advantage Silver HMO Plans
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Policy Books
- S9J3ADT Blue Advantage Silver HMO 101
- S9J4ADT Blue Advantage Silver HMO 101-in-vitro
- S9J5ADT Blue Advantage Silver HMO 102
- S9J6ADT Blue Advantage Silver HMO 102-in-vitro
- S9K2ADT Blue Advantage Silver HMO 120
- S9J7ADT Blue Advantage Silver HMO 127
- S9J8ADT Blue Advantage Silver HMO 127-in-vitro
- S9J9ADT Blue Advantage Silver HMO 134
- S9K1ADT Blue Advantage Silver HMO 134-in-vitro
- S9L1ADT Blue Advantage Silver HMO 201
- S9L2ADT Blue Advantage Silver HMO 201 – in vitro
- S9N1ADT Blue Advantage Silver HMO 401
- S9N2ADT Blue Advantage Silver HMO 401-in vitro
- S9N3ADT Blue Advantage Silver HMO 402
- S9N4ADT Blue Advantage Silver HMO 402-in vitro
- S640ADT Blue Advantage Silver HMO 803
- SV40ADT Blue Advantage Silver HMO 803-in vitro
- S641ADT Blue Advantage Silver HMO 804
- SV41ADT Blue Advantage Silver HMO 804-in vitro
- S642ADT Blue Advantage Silver HMO 818
- SV42ADT Blue Advantage Silver HMO 818-in vitro
- S643ADT Blue Advantage Silver HMO 820
- SV43ADT Blue Advantage Silver HMO 820-in vitro
- S644ADT Blue Advantage Silver HMO 846
- SV44ADT Blue Advantage Silver HMO 846-in vitro
- S9E1ADT Blue Advantage Silver HMO 925
- S9E2ADT Blue Advantage Silver HMO 925-in vitro
- S9E3ADT Blue Advantage Silver HMO 935
- S9E4ADT Blue Advantage Silver HMO 935-in vitro
- S9E5ADT Blue Advantage Silver HMO 945
- S9E6ADT Blue Advantage Silver HMO 945-in vitro
Plan Descriptions
- S640ADT Blue Advantage Silver HMO 803
- SV40ADT Blue Advantage Silver HMO 803-in vitro
- S641ADT Blue Advantage Silver HMO 804
- SV41ADT Blue Advantage Silver HMO 804-in vitro
- S642ADT Blue Advantage Silver HMO 818
- SV42ADT Blue Advantage Silver HMO 818-in vitro
- S643ADT Blue Advantage Silver HMO 820
- SV43ADT Blue Advantage Silver HMO 820-in vitro
- S644ADT Blue Advantage Silver HMO 846
- SV44ADT Blue Advantage Silver HMO 846-in vitro
- S9E1ADT Blue Advantage Silver HMO 925
- S9E2ADT Blue Advantage Silver HMO 925-in vitro
- S9E3ADT Blue Advantage Silver HMO 935
- S9E4ADT Blue Advantage Silver HMO 935-in vitro
- S9E5ADT Blue Advantage Silver HMO 945
- S9E6ADT Blue Advantage Silver HMO 945-in vitro
- S9K2ADT Blue Advantage Silver HMO 120
- S9K3ADT Blue Advantage Silver HMO 120-in vitro
Bronze Plans
Blue Choice Bronze PPO Plans
Off Exchange
Policy Books
- B660CHC Blue Choice Bronze PPO 805
- BV60CHC Blue Choice Bronze PPO 805-in vitro
- B661CHC Blue Choice Bronze PPO 806
- BV61CHC Blue Choice Bronze PPO 806-in vitro
- B662CHC Blue Choice Bronze PPO 833
- BV62CHC Blue Choice Bronze PPO 833-in vitro
Blue Advantage Bronze HMO Plans
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Policy Book
- B660ADT Blue Advantage Bronze HMO 806
- BV60ADT Blue Advantage Bronze HMO 806-in vitro
- B661ADT Blue Advantage Bronze HMO 833
- BV61ADT Blue Advantage Bronze HMO 833-in vitro
- B9E1ADT Blue Advantage Bronze HMO 905
- B9E2ADT Blue Advantage Bronze HMO 905 -in vitro