2027 Schedules of Benefits and SBCs: New Hampshire

Individual Market effective 1/1/27

HMO - OFF EXCHANGE with dental SOBSBC
NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care MD0000201756
NH Local Choice HMO Gold 1400 + $0 Rx list + $0 Virtual Urgent Care MD0000201758
NH Local Choice HMO Silver 2500 + $0 Rx list + $0 Virtual Urgent Care MD0000201771
NH Local Choice HMO Silver 3500 + $0 Rx list + $0 Virtual Urgent Care MD0000201761
NH Local Choice HMO HSA Silver 3500 MD0000201763
NH Local Choice HMO Silver 5000 + $0 Rx list + $0 Virtual Urgent Care MD0000201765
NH Local Choice HMO Bronze 6500 + $0 Rx list + $0 Virtual Urgent Care MD0000201767
NH Local Choice HMO Bronze 8000 + $0 Rx list + $0 Virtual Urgent Care MD0000201768
NH Local Choice HMO HSA Bronze 6000 MD0000201769
HMO - OFF EXCHANGE without dental SOBSBC
NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care MD0000201756
NH Local Choice HMO Gold 1400 + $0 Rx list + $0 Virtual Urgent Care MD0000201758
NH Local Choice HMO Silver 2500 + $0 Rx list + $0 Virtual Urgent Care MD0000201759
NH Local Choice HMO Silver 3500 + $0 Rx list + $0 Virtual Urgent Care MD0000201760
NH Local Choice HMO HSA Silver 3500 MD0000201762
NH Local Choice HMO Silver 5000 + $0 Rx list + $0 Virtual Urgent Care MD0000201764
NH Local Choice HMO Bronze 6500 + $0 Rx list + $0 Virtual Urgent Care MD0000201767
NH Local Choice HMO Bronze 8000 + $0 Rx list + $0 Virtual Urgent Care MD0000201768
NH Local Choice HMO HSA Bronze 6000 MD0000201769
NH Local HMO Gold 2500 Standard + $0 Rx list + $0 Virtual Urgent Care MD0000201772
NH Local HMO Silver 6400 Standard + $0 Rx list + $0 Virtual Urgent Care MD0000201774
NH Local HMO Bronze 7500 Standard + $0 Rx list + $0 Virtual Urgent Care MD0000201775
HMO - ON EXCHANGE without dental SOBSBC
NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care MD0000201756
NH Local Choice HMO Gold 1400 + $0 Rx list + $0 Virtual Urgent Care MD0000201758
NH Local Choice HMO Silver 3500 + $0 Rx list + $0 Virtual Urgent Care MD0000201760
NH Local Choice HMO Silver 5000 + $0 Rx list + $0 Virtual Urgent Care MD0000201764
NH Local Choice HMO Bronze 8000 + $0 Rx list + $0 Virtual Urgent Care MD0000201768
NH Local Choice HMO HSA Bronze 6000 MD0000201769
NH Local HMO Gold 2500 Standard + $0 Rx list + $0 Virtual Urgent Care MD0000201772
NH Local HMO Silver 6400 Standard + $0 Rx list + $0 Virtual Urgent Care MD0000201774
NH Local HMO Bronze 7500 Standard + $0 Rx list + $0 Virtual Urgent Care MD0000201775
HMO - ON EXCHANGE without dental - AI/AN - LimitedSOBSBC
NH Local Choice HMO Gold + $0 Rx list + $0 Virtual Urgent Care MD0000201756
NH Local Choice HMO Gold 1400 + $0 Rx list + $0 Virtual Urgent Care MD0000201758
NH Local Choice HMO Silver 3500 + $0 Rx list + $0 Virtual Urgent Care MD0000201760
NH Local Choice HMO Silver 5000 + $0 Rx list + $0 Virtual Urgent Care MD0000201764
NH Local Choice HMO Bronze 8000 + $0 Rx list + $0 Virtual Urgent Care MD0000201768
NH Local Choice HMO Bronze 6000 MD0000201770
NH Local HMO Gold 2500 Standard + $0 Rx list + $0 Virtual Urgent Care MD0000201772
NH Local HMO Silver 6400 Standard + $0 Rx list + $0 Virtual Urgent Care MD0000201774
NH Local HMO Bronze 7500 Standard + $0 Rx list + $0 Virtual Urgent Care MD0000201775
HMO - ON EXCHANGE without dental - AI/AN - $0 costSOBSBC
NH Local Choice HMO CSR100 MD0000201757
NH Local Choice HMO CSR100 MD0000201757
NH Local Choice HMO CSR100 MD0000201757
NH Local Choice HMO CSR100 MD0000201757
NH Local Choice HMO CSR100 MD0000201757
NH Local Choice HMO CSR100 MD0000201757
NH Local HMO CSR100 MD0000201773
NH Local HMO CSR100 MD0000201773
NH Local HMO CSR100 MD0000201773
HMO - ON EXCHANGE without dental - CSR - 73%SOBSBC
NH Local Choice HMO Silver 2500 CSR73 + $0 Rx list + $0 Virtual Urgent Care MD0000201776
NH Local Choice HMO Silver 3500 CSR73 + $0 Rx list + $0 Virtual Urgent Care MD0000201779
NH Local HMO Silver 2900 Standard CSR73 + $0 Rx list + $0 Virtual Urgent Care MD0000201782
HMO - ON EXCHANGE without dental - CSR - 87%SOBSBC
NH Local Choice HMO Silver 1400 CSR87 + $0 Rx list + $0 Virtual Urgent Care MD0000201777
NH Local Choice HMO Silver 1600 CSR87 + $0 Rx list + $0 Virtual Urgent Care MD0000201780
NH Local HMO Silver 800 Standard CSR87 + $0 Rx list + $0 Virtual Urgent Care MD0000201783
HMO - ON EXCHANGE without dental - CSR - 94%SOBSBC
NH Local Choice HMO Silver 400 CSR94 + $0 Rx list + $0 Virtual Urgent Care MD0000201778
NH Local Choice HMO Silver 500 CSR94 + $0 Rx list + $0 Virtual Urgent Care MD0000201781
NH Local HMO Silver Standard CSR94 + $0 Rx list + $0 Virtual Urgent Care MD0000201784