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
Blue Preferred Platinum EPO Plans
Off Exchange
- P821PFR Blue Preferred Platinum EPO 128
- P820PFR Blue Preferred Platinum EPO 127
- P730PFR Blue Preferred Platinum 301
Blue Advantage Platinum HMO Plans
Blue HMO Network Platinum Plans
Gold Plans
Blue PPO Gold Plans
Off Exchange
- 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
- G730PPO Blue PPO Gold 302
Blue HMO Network Gold Plans
Off Exchange
- G7E1HMO Blue HMO Network Gold 204
- G7E3HMO Blue HMO Network Gold 205
- G7N1HMO Blue HMO Network Gold 401
Blue Advantage Gold Plans
Off Exchange
- G7E1ADT Blue Advantage Gold HMO 207
- G7J5ADT Blue Advantage Gold HMO 209
- G7N1ADT Blue Advantage Gold HMO 401
Blue Preferred EPO Gold Plans
Off Exchange
- 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
- G730PFR Blue Preferred Gold EPO 302
- G821PFR Blue Preferred Gold EPO 103
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
- S751PPO Blue PPO Silver 101
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