2025 Schedules of Benefits and SBCs: Rhode Island

Small group effective 1/1/25

HMO - OFF EXCHANGE with dental SOBSBC
HMO 500 MD0000201553
HMO 1000 MD0000201547
HMO 1500 MD0000201550
HMO 1500 Value MD0000201554
HMO 2000/0% MD0000201551
HMO 2000/20% MD0000201555
HMO 3000/0% MD0000201564
HMO 3000/20% MD0000201552
HMO 4000 MD0000201565
HMO 4000 Value MD0000201560
HMO 5000 MD0000201569
HMO 6000 MD0000201556
HMO HSA 1650 MD0000201541
HMO HSA 2500 MD0000201542
HMO HSA 3000 MD0000201543
HMO HSA 4000 MD0000201544
HMO HSA 7250 MD0000201545
HMO - OFF EXCHANGE without dental SOBSBC
HMO 500 MD0000201553
HMO 1000 MD0000201547
HMO 1500 MD0000201550
HMO 1500 Value MD0000201554
HMO 2000/0% MD0000201551
HMO 2000/20% MD0000201555
HMO 3000/0% MD0000201564
HMO 3000/20% MD0000201552
HMO 4000 MD0000201565
HMO 4000 Value MD0000201560
HMO 5000 MD0000201569
HMO 6000 MD0000201556
HMO HSA 1650 MD0000201541
HMO HSA 2500 MD0000201542
HMO HSA 3000 MD0000201543
HMO HSA 4000 MD0000201544
HMO HSA 7250 MD0000201545
PPO - OFF EXCHANGE with dental SOBSBC
PPO Access 500 MD0000201566
PPO Access 1000 MD0000201557
PPO Access 1500 MD0000201558
PPO Access 2000/0% MD0000201559
PPO Access 2000/20% MD0000201561
PPO Access 3000/0% MD0000201567
PPO Access 3000/20% MD0000201568
PPO Access 4000 MD0000201562
PPO Access 4000 Value MD0000201563
PPO Access 5000 MD0000201570
PPO Access 6000 MD0000201571
PPO Access HSA 1650 MD0000201546
PPO Access HSA 2500 MD0000201548
PPO Access HSA 3000 MD0000201572
PPO Access HSA 4000 MD0000201549
PPO Access HSA 7250 MD0000201573
PPO - OFF EXCHANGE without dental SOBSBC
PPO Access 500 MD0000201566
PPO Access 1000 MD0000201557
PPO Access 1500 MD0000201558
PPO Access 2000/0% MD0000201559
PPO Access 2000/20% MD0000201561
PPO Access 3000/0% MD0000201567
PPO Access 3000/20% MD0000201568
PPO Access 4000 MD0000201562
PPO Access 4000 Value MD0000201563
PPO Access 5000 MD0000201570
PPO Access 6000 MD0000201571
PPO Access HSA 1650 MD0000201546
PPO Access HSA 2500 MD0000201548
PPO Access HSA 3000 MD0000201572
PPO Access HSA 4000 MD0000201549
PPO Access HSA 7250 MD0000201573