2025 QHP Small Group Actual Policy Documents

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 1-866-520-2507 for more information.

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Platinum Plans

Blue Preferred Platinum PPO Plans
Off Exchange

• P710PFR Blue Preferred Platinum PPO 401 
• P8E1PFR Blue Preferred Platinum PPO 416
• P8K4PFR Blue Preferred Platinum PPO 420
• P8K1PFR Blue Preferred Platinum PPO 421

Blue Advantage Platinum PPO Plans
Off Exchange

• P710ADT Blue Advantage Platinum PPO 101 
• P8E1ADT Blue Advantage Platinum PPO 116 
• P8J6ADT Blue Advantage Platinum PPO 118
• P8K1ADT Blue Advantage Platinum PPO 122

Blue Options Platinum PPO Plans
Off Exchange

• P8J7OPT Blue Options Platinum PPO 311

Blue Choice Platinum PPO Plans
Off Exchange

• P8J1CHC Blue Choice Platinum PPO 208

Gold Plans

Blue Choice Gold PPO Plans
Off Exchange

• G730CHC Blue Choice Gold PPO 201 
• G731CHC Blue Choice Gold PPO 202 
• G732CHC Blue Choice Gold PPO 203

Blue Preferred Gold PPO Plans
Off Exchange

• G730PFR Blue Preferred Gold PPO 402 
• G731PFR Blue Preferred Gold PPO 403 
• G733PFR Blue Preferred Gold PPO 410 
• G735PFR Blue Preferred Gold PPO 412 
• G8J2PFR Blue Preferred Gold PPO 418
• G8K5PFR Blue Preferred Gold PPO 423
• G8K3PFR Blue Preferred Gold PPO 424
• G8K6PFR Blue Preferred Gold PPO 426 
• G8M1PFR Blue Preferred Gold PPO 434
• G8M2PFR Blue Preferred Gold PPO 435

Blue Advantage Gold PPO Plans
Off Exchange

• G740ADT Blue Advantage Gold PPO 102 
• G743ADT Blue Advantage Gold PPO 108 
• G744ADT Blue Advantage Gold PPO 109 
• G745ADT Blue Advantage Gold PPO 110 
• G746ADT Blue Advantage Gold PPO 112 
• G8J3ADT Blue Advantage Gold PPO 119
• G8K3ADT Blue Advantage Gold PPO 124
• G8K6ADT Blue Advantage Gold PPO 126 
• G8M1ADT Blue Advantage Gold PPO 135
• G8M2ADT Blue Advantage Gold PPO 136

Blue Options Gold PPO
Off Exchange

• G720OPT Blue Options Gold PPO 301 
• G721OPT Blue Options Gold PPO 302

Silver Plans

Blue Choice Silver PPO Plans
Off Exchange

• S730CHC Blue Choice Silver PPO 204
• S8J9CHC Blue Choice Silver PPO 209

Blue Preferred Silver PPO Plans
Off Exchange

• S731PFR Blue Preferred Silver PPO 405 
• S732PFR Blue Preferred Silver PPO 406 
• S8K1PFR Blue Preferred Silver PPO 413 
• S8E1PFR Blue Preferred Silver PPO 417 
• S8J5PFR Blue Preferred Silver PPO 419
• S8K9PFR Blue Preferred Silver PPO 427
• S8K0PFR Blue Preferred Silver PPO 429 
• S8K5PFR Blue Preferred Silver PPO 430
• S8K8PFR Blue Preferred Silver PPO 433

Blue Advantage Silver PPO Plans
Off Exchange

• S730ADT Blue Advantage Silver PPO 104 
• S731ADT Blue Advantage Silver PPO 105
• S8K1ADT Blue Advantage Silver PPO 114
• S702ADT Blue Advantage Silver PPO 115
• S8E1ADT Blue Advantage Silver PPO 117 
• S8J4ADT Blue Advantage Silver PPO 121 
• S8K9ADT Blue Advantage Silver PPO 129
• S8K5ADT Blue Advantage Silver PPO 131
• S8K8ADT Blue Advantage Silver PPO 134

Blue Options Silver PPO
Off Exchange

• S710OPT Blue Options Silver PPO 304 
• S8E1OPT Blue Options Silver PPO 310
• S8J0OPT Blue Options Silver PPO 312

Bronze Plans

Blue Choice Bronze PPO Plans
Off Exchange

• B730CHC Blue Choice Bronze PPO 207

Blue Preferred Bronze PPO Plans
Off Exchange

• B730PFR Blue Preferred Bronze PPO 407
• B8K0PFR Blue Preferred Bronze PPO 428

Blue Advantage Bronze PPO Plans
Off Exchange

• B730ADT Blue Advantage Bronze PPO 106
• B8K0ADT Blue Advantage Bronze PPO 130

Blue Options Bronze PPO
Off Exchange

• B710OPT Blue Options Bronze PPO 306

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