Please complete & return this form in its entirety, including the required signatures
Section 1 - Account Information:
Employer Name:
BlueSTAR Account #: / Effective Date: / Anniversary Date:
Health Products / Mid-Market Benefit Plan Selection:
·  The OPX in all non-HSA plans listed below will not exceed $1,000 for RX or $5,600 for Medical for Individual; and $3,000 for RX or $10,200 for Medical for Family. For HSA plans, the OPX will not exceed $6,450. The OPX is inclusive of all deductibles, copays and coinsurance costs incurred on in-network benefits.
·  There are four health product categories which include multiple products (i.e. Blue Choice PPO) and their applicable benefit plans.
·  A group may select up to six health plan options.
·  The Prescription Drug Card may vary between products.
Section 2a - Renewing Groups Only: (*If New Business, skip to Section 3)
Current Plan:
Please list current plan(s) below / Retaining Plan: / Replacing Plan:
Please list replacement plan in space below.
1.  / Yes No
2.  / Yes No
3.  / Yes No
4.  / Yes No
5.  / Yes No
6.  / Yes No
Section 2b - Renewing Groups Only: (*If New Business, skip to Section 3)
Adding Plan (Medical and/or Dental):
Please list new plan(s) below
1. 
2. 
3. 
4. 
5. 
6. 
Section 3 – HSA / FSA Plans:
HSA Vendor:
* If HSA is selected, a vendor will need to be selected.
(If no selection is made, HSA Vendor will default to Other / None.) / FSA Vendor:
* If FSA is selected, a vendor will need to be selected.
(If no selection is made, FSA Vendor will default to Other / None.)
Option A: BenefitWallet / Option D: FSA ConnectYourCare
Option B: HSA Bank / Option E: FSA Other / None
Option C: FlexHSA / Option F: HSA Other / None
Section 4 – New Business: GROUP NUMBER:
1.  Blue Directions (Private Exchange) Purchased? Yes No (If yes, the Blue Directions Addendum is attached and made a part of the policy.)
2.  Please select plan designs (Up to a maximum of 6 plans)
A.  Blue Choice Options SM
Tiered Network (Blue Choice OPT PPO – BC / PPO – PPO / Out of Network - OON)
2017 NRMM Plan ID / Deductible
BC / PPO / OON / CoIns
BC / PPO / OON / OPX
BC / PPO / OON / PCP Copay
BC/ PPO / ER Copay
BC / PPO / Preferred Pharmacy
Network
MTP72C2F / $500 / $1,500 / $3,000 / 90%/ 70% / 50% / $4,000 / $5,600 / $12,000 / $20 / $50 / $400* / $400* / $0/$10/$35/$75/$150
MTP8274F / $1,000 / $2,500 / $5,000 / 90% / 70% / 50% / $2,500 / $5,500 / $11,000 / $25 / $50 / $400* / $400* / $0/$10/$35/$75/$150
MTET1V07 / $2,600 / $4,500 / $9,000 / 100% / 80% / 60% / $2,600 / $6,450 /$12,900 / N/A / N/A / N/A / N/A / 100%
MTPF3Q5F / $4,000 / $5,000 / $10,000 / 80% / 60% / 50% / $5,600 / $5,600 / $13,200 / $35 / $60 / $500* / $500* / $0/$10/$35/$75/$150
MTP7122F / $500 / $1,500 / $3,000 / 100% / 70% / 50% / $500 / $3,000 / $6,000 / $20 / $50 / $400* / $400* / $0/$10/$35/$75/$150
MTP7272F / $500 / $1,500 / $3,000 / 90% / 70% / 50% / $2,500 / $5,500 / $11,000 / $20 / $50 / $400* / $400* / $0/$10/$35/$75/$150
MTP9253F / $1,500 / $3,500 / $7,000 / 90% / 70% / 50% / $3,000 / $5,500 / $11,000 / $30 / $50 / $400* / $400* / $0/$10/$35/$75/$150
B. Blue Choice Select SM
2017 NRMM Plan ID / Deductible
In/Out / CoIns
In/Out / OPX
In/Out / PCP Copay / ER Copay / Preferred Pharmacy
Network
MBPC3836 / $2,500 / $5,000 / 80% / 50% / $4,500 / $9,000 / $30 / $150 / $10/$40/$60
MBP72326 / $500 / $1,000 / 90% / 60% / $1,500 / $3,000 / $20 / $150 / $10/$40/$60
MBP92326 / $1,500 / $3,000 / 90% / 60% / $2,500 / $5,000 / $20 / $150 / $10/$40/$60
MBP93C3C / $1,500 / $3,000 / 80% / 50% / $3,500 / $7,000 / $30 / $150 / $8/$35/$75/$150
MBP8343C / $1,000 / $2,000 / 80% / 50% / $3,000 / $6,000 / $30 / $150 / $8/$35/$75/$150
MBP82326 / $1,000 / $2,000 / 90% / 60% / $2,000 / $4,000 / $20 / $150 / $10/$40/$60
MBP42326 / $250 / $500 / 90% / 60% / $1,250 / $2,500 / $20 / $150 / $10/$40/$60
MBP8353G / $1,000 / $2,000 / 80% / 60% / $3,000 / $6,000 / $30 / $400* / $0/$10/$50/$100/$150
MBP73436 / $500 / $1,000 / 80% / 50% / $2,500 / $5,000 / $30 / $150 / $10/$40/$60
MBPA3C3F / $2,000 / $4,000 / 80% / 60% / $4,000 / $8,000 / $30 / $150 / $0/$10/$35/$75/$150
MBPA3Q3F / $2,000 / $4,000 / 80% / 60% / $5,500 / $11,000 / $30 / $150 / $0/$10/$35/$75/$150
MBPF1C3F / $4,000 / $8,000 / 100% /100% / $4,000 / $8,000 / $30 / $150 / $0/$10/$35/$75/$150
MBPF3Q3F / $4,000 / $8,000 / 80% /60% / $5,500 / $11,000 / $30 / $150 / $0/$10/$35/$75/$150
C. BlueEdge SM Select HSA – Asterisk (*) Indicates Aggregate Plan
2017 NRMM Plan ID / Deductible
In/Out / CoIns
In/Out / OPX
In/Out / PCP Copay / ER Copay / Rx Plan
Network
MBSC1807* / $2,500 / $5,000 / 100% / 70% / $2,500 / $5,000 / 100% / 100% / 100%
MBSC3805* / $2,500 / $5,000 / 80% / 50% / $5,000 / $10,000 / 80% / 80% / 80%
D. CPO - This Product is not available in all geographic areas
Tiered Network: Community Preferred Option-CPO/PPO/Out of Network - OON
2017 NRMM Plan ID / Deductible
CPO/PPO/OON / CoIns
CPO/PPO/OON / OPX
CPO/PPO/OON / PCP Copay
CPO/PPO/OON / ER Copay
CPO/PPO/OON / Preferred Pharmacy
Network
MCP72O2C / $500/$1,000/$2,000 / 90%/80%/60% / $2,500/$5,000/$14,000 / $20/$20/$20 / $150/$150/$150 / $8/$35/$75/$150
Initial Employee Enrollment by CPO Network / CO______# of Ees______
CO______# of Ees______
CO______# of Ees______
Total # of Employees Enrolled:______
E. CPO Value Choice -This Product is not available in all geographic areas
Tiered Network: Community Preferred Option-CPO/PPO/Out of Network - OON
2017 NRMM Plan ID / Deductible
CPO/PPO/OON / CoIn
CPO/PPO/OON / OPX
CPO/PPO/OON / PCP Copay
CPO/PPO/OON / ER Copay
CPO/PPO/OON / Rx Plan
Network
MCV82305 / $1,000/$2,000/$4,000 / 90%/80%/50% / $2,000/$4,000/$8,000 / 90%/80%/50% / $150/$150/$150 / 80%
Initial Employee Enrollment by CPO Network / CO______# of Ees______
CO______# of Ees______
CO______# of Ees______
Total # of Employees Enrolled:__
*ER Copay is per occurrence
F. BlueEdge SM HSA - Asterisk (*) Indicates Aggregate Plan
2017 NRMM Plan ID / Deductible
In/Out / CoIns
In/Out / OPX
In/Out / PCP Copay / ER Copay / Rx Plan
Network
MPSC1807 / $2,500 / $2,500 / 100% / 80% / $5,000 /$5,000 / 100% / 100% / 100%
MPET1V07 / $2,600 / $5,200 / 100% / 80% / $2,600 / $10,400 / 100% / 100% / 100%
MPET3Y05 / $2,600 / $5,200 / 80% / 60% / $5,200 / $10,400 / 80% / 80% / 80%
MPS91605 / $1,500 /$1,500 / 100% / 80% / $3,000 / $3,000 / 100% / 100% / 80%
MPET290H / $2,600 / $5,200 / 90% / 70% / $3,500 / $7,000 / 90% / 90% / 90%
MPS93505 / $1,500 / $3,000 / 80% / 60% / $3,000 / $6,000 / 80% / 80% / 80%
MPPO1Q07 / $6,000 / $12,000 / 100% / 100% / $6,000 / $12,000 / 100% / 100% / 100%
MPSC3805* / $2,500 / $5,000 / 80% / 60% / $5,000 / $10,000 / 80% / 80% / 80%
MPSE3X05* / $3,500 / $7,000 / 80% / 60% / $5,800 / $11,600 / 80% / 80% / 80%
G. Blue Advantage ®HMO
2017 NRMM Plan ID / Deductible
In Network / CoIns
In Network / OPX
In Network / PCP Copay
In Network / ER Copay
In Network / Rx Plan
Network
MHHB196 / $0 / N/A / $1,500 / $30 / $150 / $10/$40/$60
MHHB106 / $0 / N/A / $1,500 / $20 / $150 / $10/$40/$60
MHHB166 / $0 / N/A / $1,500 / $30 / $150 / $10/$40/$60
MHHB19C / $0 / N/A / $1,500 / $30 / $150 / $8/$35/$75/$150
MHH11S3F / $0 / 100% / $5,600 / $30 / $400* / $0/$10/$35/$75/$150
H. Blue Advantage HMO® Value Choice
2017 NRMM Plan ID / Deductible
In Network / CoIns
In Network / OPX
In Network / PCP Copay
In Network / ER Copay
In Network / Rx Plan
Network
MHVBV02C / $0 / N/A / $3,000 / $40 / $250 / $8/$35/$75/$150
MHVBV03C / $0 / N/A / $3,000 / $50 / $300 / $8/$35/$75/$150
I. Blue Print® PPO
2017 NRMM Plan ID / Deductible
In/Out / CoIns
In/Out / OPX
In/Out / PCP Copay / ER Copay / Preferred Pharmacy
Network
MPP83436 / $1,000 / $2,000 / 80% / 60% / $3,000 / $6,000 / $30 / $150 / $10/$40/$60
MPP82326 / $1,000 / $2,000 / 90% / 70% / $2,000 / $4,000 / $20 / $150 / $10/$40/$60
MPP83D36 / $1,000 / $2,000 / 80% / 60% / $4,000 / $8,000 / $30 / $150 / $10/$40/$60
MPP8343C / $1,000 / $2,000 / 80% / 60% / $3,000 / $6,000 / $30 / $150 / $8/$35/$75/$150
MPP93C36 / $1,500 / $3,000 / 80% / 60% / $3,500 / $7,000 / $30 / $150 / $10/$40/$60
MPP9383C / $1,500 / $3,000 / 80% / 60% / $4,500 / $9,000 / $30 / $150 / $8/$35/$75/$150
MPPC3836 / $2,500 / $5,000 / 80% / 60% / $4,500 / $9,000 / $30 / $150 / $10/$40/$60
MPPC3Q36 / $2,500 / $5,000 / 80% / 60% / $5,500 / $11,000 / $30 / $150 / $10/$40/$60
MPPC3826 / $2,500 / $5,000 / 80% / 60% / $4,500 / $9,000 / $20 / $150 / $10/$40/$60
MPPC2C26 / $2,500 / $5,000 / 90% / 70% / $3,500 / $7,000 / $20 / $150 / $10/$40/$60
MPP43323 / $250 / $500 / 80% / 60% / $1,250 / $2,500 / $20 / $150 / $15/$30/$50
MPPE3Q26 / $3,500 / $7,000 / 80% / 60% / $5,500 / $11,000 / $20 / $150 / $10/$40/$60
MPP73426 / $500 / $1,000 / 80% / 60% / $2,500 / $5,000 / $20 / $150 / $10/$40/$60
MPP72326 / $500 / $1,000 / 90% / 70% / $1,500 / $3,000 / $20 / $150 / $10/$40/$60
MPP43M4F / $250 / $500 / 80% / 60% / $1,250 / $2,500 / $25 / $300* / $0/$10/$35/$75/$150
MPP8353G / $1,000 / $2,000 / 80% / 60% / $3,000 / $6,000 / $30 / $400* / $0/$10/$50/$100/$150
MPP73863 / $500 / $1,000 / 80% / 60% / $5,000 / $10,000 / $40 / $400* / $15/$30/$50
MPP9391F / $1,500 / $3,000 / 80% / 60% / $3,500 / $7,000 / $10 / $400* / $0/$10/$35/$75/$150
MPP11T3F / $0 / $6,600 / 100% / 80% / $5,600 / $13,200 / $30 / $400* / $0/$10/$35/$75/$150
MPP73436 / $500 / $1,000 / 80% / 60% / $2,500 / $5,000 / $30 / $150 / $10/$40/$60
MPP72226 / $500 / $1,000 / 90% / 70% / $1,000 / $2,000 / $20 / $150 / $10/$40/$60
MPP73C3C / $500 / $1,000 / 80% / 60% / $3,500 / $7,000 / $30 / $150 / $8/$35/$75/$150
MPP93C26 / $1,500 / $3,000 / 80% / 60% / $3,500 / $7,000 / $20 / $150 / $10/$40/$60
MPP93C3C / $1,500 / $3,000 / 80% / 60% / $3,500 / $7,000 / $30 / $150 / $8/$35/$75/$150
MPP12J2G / $0 / $0 / 90% / 70% / $250 / $1,000 / $20 / $150 / $0/$10/$50/$100/$150
MPPA3C3F / $2,000 / $4,000 / 80% / 60% / $4,000 / $8,000 / $30 / $150 / $0/$10/$35/$75/$150
MPPA3Q3F / $2,000 / $4,000 / 80% / 60% / $5,500 / $11,000 / $30 / $150 / $0/$10/$35/$75/$150
MPPF1C3F / $4,000 / $8,000 / 100% / 100% / $4,000 / $8,000 / $30 / $150 / $0/$10/$35/$75/$150
MPPF3Q3F / $4,000 / $8,000 / 80% / 60% / $5,500 / $11,000 / $30 / $150 / $0/$10/$35/$75/$150
MPPH3T6G / $5,000 / $10,000 / 80% / 60% / $5,600 / $12,200 / $40 / $250 / $0/$10/$50/$100/$150
*ER Copay is Per Occurrence
Section 5 – Ancillary Products: / DENTAL PPO GROUP NUMBER:
DENTAL HMO GROUP NUMBER:
1. Blue Care Dental*
Plan Pairings (Groups 10+)
True Group
Any one of the following three True Group High Option plans, DINHR01, DINHR02 or DINHR03 can be paired with any one of the following True Group Low Option plans, DINLR06, DINLR07, or DINLM09; DINHM12 can be freely paired with any True Group.
High Option Low Option
DINHR01 DINLR06
DINHR02 DINLR07
DINHR03 DINLM09 / Voluntary
Any one voluntary high option can be paired with any one voluntary low option; DINHM16 can be freely paired freely with any voluntary option
High Option Low Option
DINHR13 DINLM15
DINHM14 DINHM16 / Participation Requirements
True Group
>70% participation
>50% employer contribution / Voluntary
>25% participation
Employers are not required to contribute to Voluntary Dental plans
Plan ID / Eligibility / Deductible (In/Out) / Annual Max / CoIns (In/Out) - Class I / Ortho Maximum / Plan Type / Allocation / Segment
DINHR01 / Full / $25/$25 / $3,000 / 100%/100% / $2,000 / Passive / High / True Group
DINHR02 / Full / $50/$50 / $2,000 / 100%/100% / $2,000 / Passive / High / True Group
DINHR03 / Full / $50/$50 / $1,500 / 100%/100% / $1,500 / Passive / High / True Group
DINHR04 / Full / $50/$75 / $1,500 / $1,000 / 100%/80% / $1,000 / Active / High / True Group
DINLR05 / Full / $50/$50 / $1,000 / 100%/100% / $1,000 / Passive / Low / True Group
DINLR06 / Full / $50/$50 / $1,000 / 100%/100% / N/A / Passive / Low / True Group
DINLR07 / Full / $75/$75 / $1,000 / 90%/90% / N/A / Passive / Low / True Group
DINHM08 / Full / $50/$50 / $1,000 / 100%/100% / $1,000 / Passive / High / True Group
DINLM09 / Full / $50/$50 / $1,000 / 100%/100% / N/A / Passive / Low / True Group
DINHM10 / Full / $50/$50 / $1,500 / $1,000 / 100%/80% / N/A / Active / High / True Group
DINLM11 / Full / $75/$75 / $1,000 / 90%/70% / N/A / Active / Low / True Group
DINHM12 / Full / $25/$75 / $750 / 100%/100% / N/A / Passive / High / True Group
DINHR13 / Full / $50/$50 / $1,500 / 100%/100% / $1,500 / Passive / High / Voluntary
DINHM14 / Full / $50/$50 / $1,500 / $1,000 / 100%/80% / N/A / Active / High / Voluntary
DINLM15 / Full / $75/$75 / $1,000 / 90%/70% / N/A / Active / Low / Voluntary
DINHM16 / Full / $25/$75 / $750 / 100%/100% / N/A / Passive / High / Voluntary
2. Blue Care Dental HMO
Plan Pairings (Groups 10+)
True Group
Any one True Group DHMO can be paired with any one True Group PPO option. / Voluntary
Any one Voluntary DHMO option can be paired with one Voluntary PPO option. / Participation Requirements