2027 Schedules of Benefits and SBCs: Maine

Individual Market effective 1/1/27

HMO - OFF EXCHANGE with dental	SOB	SBC
Clear Choice HMO Gold 2000 MD0000201883
Clear Choice Maine's Choice Plus HMO Gold 2000 MD0000201885
Clear Choice HMO Gold 3000 MD0000201886
Clear Choice Maine's Choice Plus HMO Gold 3000 MD0000201888
HMO Silver 4000 MD0000201893
Maine's Choice Plus HMO Silver 4000 MD0000201894
Clear Choice HMO Silver 4500 MD0000201896
Clear Choice Maine's Choice Plus HMO Silver 4500 MD0000201901
Clear Choice Maine's Choice Plus HMO HSA Silver 4000 MD0000201909
Clear Choice HMO HSA Silver 5000 MD0000201911
Clear Choice Maine's Choice Plus HMO HSA Silver 5000 MD0000201912
Clear Choice HMO Silver 6000 MD0000201916
Clear Choice Maine's Choice Plus HMO Silver 6000 MD0000201920
Maine's Choice Plus HMO Silver 7000 MD0000201924
Clear Choice HMO Bronze 7000 MD0000201925
Maine's Choice Plus HMO HSA Bronze 7200 MD0000201926
Clear Choice Maine's Choice Plus HMO Bronze 7000 MD0000201932
HMO HSA Bronze 7200 MD0000201933
Clear Choice HMO HSA Bronze 7500 MD0000201934
Clear Choice Maine's Choice Plus HMO HSA Bronze 7500 MD0000201935
Clear Choice HMO HSA Bronze 8700 MD0000201943

HMO - OFF EXCHANGE without dental	SOB	SBC
Clear Choice HMO Gold 2000 MD0000201883
Clear Choice HMO Gold 3000 MD0000201886
Clear Choice Maine's Choice Plus HMO Gold 3000 MD0000201888
Clear Choice HMO Silver 4500 MD0000201896
Clear Choice Maine's Choice Plus HMO Silver 4500 MD0000201901
Clear Choice HMO Silver 6000 MD0000201916
Clear Choice Maine's Choice Plus HMO Silver 6000 MD0000201920
Clear Choice HMO HSA Bronze 7500 MD0000201934
Clear Choice Maine's Choice Plus HMO HSA Bronze 7500 MD0000201935

HMO - ON EXCHANGE without dental	SOB	SBC
Clear Choice HMO Gold 2000 MD0000201883
Clear Choice HMO Gold 3000 MD0000201886
Clear Choice Maine's Choice Plus HMO Gold 3000 MD0000201888
Clear Choice HMO Silver 4500 MD0000201900
Clear Choice Maine's Choice Plus HMO Silver 4500 MD0000201906
Clear Choice HMO Silver 6000 MD0000201940
Clear Choice Maine's Choice Plus HMO Silver 6000 MD0000201931
Clear Choice HMO HSA Bronze 7500 MD0000201934
Clear Choice Maine's Choice Plus HMO HSA Bronze 7500 MD0000201935

HMO - ON EXCHANGE without dental - AI/AN - Limited	SOB	SBC
Clear Choice HMO Gold 2000 MD0000201883
Clear Choice HMO Gold 3000 MD0000201886
Clear Choice Maine's Choice Plus HMO Gold 3000 MD0000201888
Clear Choice HMO Silver 4500 MD0000201896
Clear Choice Maine's Choice Plus HMO Silver 4500 MD0000201901
Clear Choice HMO Silver 6000 MD0000201916
Clear Choice Maine's Choice Plus HMO Silver 6000 MD0000201920
Clear Choice HMO HSA Bronze 7500 MD0000201934
Clear Choice Maine's Choice Plus HMO HSA Bronze 7500 MD0000201935

HMO - ON EXCHANGE without dental - AI/AN - $0	SOB	SBC
HMO CSR 100 MD0000201884
HMO CSR 100 MD0000201884
Maine's Choice Plus HMO CSR 100 MD0000201890
HMO CSR 100 MD0000201884
Maine's Choice Plus HMO CSR 100 MD0000201890
HMO CSR 100 MD0000201884
Maine's Choice Plus HMO CSR 100 MD0000201890
HMO CSR 100 MD0000201884
Maine's Choice Plus HMO CSR 100 MD0000201890

EPO - OFF EXCHANGE with dental	SOB	SBC
Clear Choice National Access Gold 3000 MD0000201889
Clear Choice National Access Silver 4500 MD0000201907
Clear Choice National Access HSA Silver 4000 MD0000201910
Clear Choice National Access HSA Bronze 7500 MD0000201938
Clear Choice National Access HSA Bronze 8700 MD0000201936
National Access Silver 4000 MD0000201946

EPO - OFF EXCHANGE without dental	SOB	SBC
Clear Choice National Access Gold 3000 MD0000201889
Clear Choice National Access Silver 4500 MD0000201907
Clear Choice National Access HSA Bronze 7500 MD0000201938

EPO - ON EXCHANGE without dental	SOB	SBC
Clear Choice National Access Gold 3000 MD0000201889
Clear Choice National Access Silver 4500 MD0000201930
Clear Choice National Access HSA Bronze 7500 MD0000201938

EPO - ON EXCHANGE without dental - AI/AN - Limited	SOB	SBC
Clear Choice National Access Gold 3000 MD0000201889
Clear Choice National Access Silver 4500 MD0000201907
Clear Choice National Access HSA Bronze 7500 MD0000201938

EPO - ON EXCHANGE without dental - AI/AN - $0	SOB	SBC
National Access CSR 100 MD0000201891
National Access CSR 100 MD0000201891
National Access CSR 100 MD0000201891

PPO - OFF EXCHANGE with dental	SOB	SBC
Clear Choice PPO Access Gold 3000 MD0000201892
PPO Access Silver 4000 MD0000201895
Clear Choice PPO Access Silver 4500 MD0000201908
Clear Choice PPO Access HSA Silver 5000 MD0000201915
Clear Choice PPO Access HSA Bronze 8700 MD0000201945

HMO - ON EXCHANGE without dental - CSR - 73%	SOB	SBC
Clear Choice HMO Silver 3600 CSR 73 MD0000201897
Clear Choice Maine's Choice Plus HMO Silver 3600 CSR 73 MD0000201903
Clear Choice HMO Silver 4500 CSR 73 MD0000201917
Clear Choice Maine's Choice Plus HMO Silver 4500 CSR 73 MD0000201921

HMO - ON EXCHANGE without dental - CSR - 87%	SOB	SBC
Clear Choice HMO Silver 800 CSR 87 MD0000201898
Clear Choice Maine's Choice Plus HMO Silver 800 CSR 87 MD0000201904
Clear Choice HMO Silver 1000 CSR 87 MD0000201918
Clear Choice Maine's Choice Plus HMO Silver 1000 CSR 87 MD0000201922

HMO - ON EXCHANGE without dental - CSR - 94%	SOB	SBC
Clear Choice HMO Silver 400 CSR 94 MD0000201899
Clear Choice Maine's Choice Plus HMO Silver 400 CSR 94 MD0000201905
Clear Choice HMO Silver 500 CSR 94 MD0000201919
Clear Choice Maine's Choice Plus HMO Silver 500 CSR 94 MD0000201923

EPO - ON EXCHANGE without dental - CSR - 73%	SOB	SBC
Clear Choice National Access Silver 3600 CSR 73 MD0000201927

EPO - ON EXCHANGE without dental - CSR - 87%	SOB	SBC
Clear Choice National Access Silver 800 CSR 87 MD0000201928

EPO - ON EXCHANGE without dental - CSR - 94%	SOB	SBC
Clear Choice National Access Silver 400 CSR 94 MD0000201929