Schedules of Benefits and SBCs: Maine

Individual Market effective 1/1/23

HMO - OFF EXCHANGE with Dental SOB SBC
Clear Choice HMO Gold 1500 MD0000200368
Clear Choice HMO Gold 2500 MD0000200369
Clear Choice HMO Silver 3000 MD0000200370
Clear Choice HMO Silver 3500 MD0000200373
Clear Choice HMO Silver 4200 MD0000200376
Clear Choice HMO HSA Silver 3000 MD0000200378
Clear Choice Maine's Choice Plus HMO HSA Silver 3000 MD0000200379
Clear Choice HMO HSA Silver 3500 MD0000200382
Clear Choice Maine's Choice Plus HMO HSA Silver 3500 MD0000200383
Clear Choice HMO HSA Silver 4000 MD0000200384
Clear Choice HMO HSA Silver 4500 MD0000200385
Clear Choice HMO HSA Bronze 5200 MD0000200386
Clear Choice HMO HSA Bronze 5900 MD0000200387
Clear Choice HMO HSA Bronze 6300 MD0000200388
Clear Choice HMO HSA Bronze 7000 MD0000200389
Clear Choice Maine's Choice Plus HMO HSA Silver 4000 MD0000200390
Clear Choice Maine's Choice Plus HMO HSA Silver 4500 MD0000200391
Clear Choice Maine's Choice Plus HMO HSA Bronze 5200 MD0000200392
Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 MD0000200393
Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 MD0000200394
Clear Choice HMO Silver 5500 MD0000200408
Clear Choice HMO Silver 6000 MD0000200410
Clear Choice HMO Bronze 7500 MD0000200411
Clear Choice HMO Bronze 8000 MD0000200412
Clear Choice HMO Bronze 9100 MD0000200413
Clear Choice HMO Catastrophic 9100 MD0000200414
Clear Choice Maine's Choice Plus HMO Gold 1500 MD0000200431
Clear Choice Maine's Choice Plus HMO Gold 2500 MD0000200432
Clear Choice Maine's Choice Plus HMO Silver 3000 MD0000200433
Clear Choice Maine's Choice Plus HMO Silver 3500 MD0000200435
Clear Choice Maine's Choice Plus HMO Silver 4200 MD0000200438
Clear Choice Maine's Choice Plus HMO Silver 6000 MD0000200440
Clear Choice Maine's Choice Plus HMO Silver 5500 MD0000200442
Clear Choice Maine's Choice Plus HMO Bronze 7500 MD0000200443
Clear Choice Maine's Choice Plus HMO Bronze 8000 MD0000200444
HMO Gold 2700 MD0000200476
Maine's Choice Plus HMO Gold 2700 MD0000200477
HMO Silver 6800 MD0000200480
Maine's Choice Plus HMO HSA Silver 3300 MD0000200482
Virtual Choice HMO Gold 2700 MD0000200489
Clear Choice Virtual Choice HMO Silver 6000 MD0000200490
HMO - OFF EXCHANGE without Dental SOB SBC
Clear Choice HMO Gold 1500 MD0000200368
Clear Choice HMO Gold 2500 MD0000200369
Clear Choice HMO Silver 3000 MD0000200372
Clear Choice HMO Silver 3500 MD0000200374
Clear Choice HMO Silver 4200 MD0000200375
Clear Choice HMO HSA Silver 3000 MD0000200377
Clear Choice Maine's Choice Plus HMO HSA Silver 3000 MD0000200380
Clear Choice HMO HSA Silver 3500 MD0000200382
Clear Choice Maine's Choice Plus HMO HSA Silver 3500 MD0000200383
Clear Choice HMO HSA Silver 4000 MD0000200384
Clear Choice HMO HSA Silver 4500 MD0000200385
Clear Choice HMO HSA Bronze 5200 MD0000200386
Clear Choice HMO HSA Bronze 5900 MD0000200387
Clear Choice HMO HSA Bronze 6300 MD0000200388
Clear Choice HMO HSA Bronze 7000 MD0000200389
Clear Choice Maine's Choice Plus HMO HSA Silver 4000 MD0000200390
Clear Choice Maine's Choice Plus HMO HSA Silver 4500 MD0000200391
Clear Choice Maine's Choice Plus HMO HSA Bronze 5200 MD0000200392
Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 MD0000200393
Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 MD0000200394
Clear Choice HMO Silver 5500 MD0000200407
Clear Choice HMO Silver 6000 MD0000200409
Clear Choice HMO Bronze 7500 MD0000200411
Clear Choice HMO Bronze 8000 MD0000200412
Clear Choice HMO Bronze 9100 MD0000200413
Clear Choice HMO Catastrophic 9100 MD0000200414
Clear Choice Maine's Choice Plus HMO Gold 1500 MD0000200431
Clear Choice Maine's Choice Plus HMO Gold 2500 MD0000200432
Clear Choice Maine's Choice Plus HMO Silver 3000 MD0000200434
Clear Choice Maine's Choice Plus HMO Silver 3500 MD0000200436
Clear Choice Maine's Choice Plus HMO Silver 4200 MD0000200437
Clear Choice Maine's Choice Plus HMO Silver 6000 MD0000200439
Clear Choice Maine's Choice Plus HMO Silver 5500 MD0000200441
Clear Choice Maine's Choice Plus HMO Bronze 7500 MD0000200443
Clear Choice Maine's Choice Plus HMO Bronze 8000 MD0000200444
HMO Gold 2700 MD0000200476
Maine's Choice Plus HMO Gold 2700 MD0000200477
HMO Silver 6800 MD0000200479
Maine's Choice Plus HMO HSA Silver 3300 MD0000200482
Virtual Choice HMO Gold 2700 MD0000200489
Clear Choice Virtual Choice HMO Silver 6000 MD0000200490
HMO - ON EXCHANGE without Dental SOB SBC
Clear Choice HMO Gold 1500 MD0000200368
Clear Choice HMO Gold 2500 MD0000200369
Clear Choice HMO Silver 3000 MD0000200372
Clear Choice HMO Silver 3500 MD0000200374
Clear Choice HMO Silver 4200 MD0000200375
Clear Choice Maine's Choice Plus HMO HSA Silver 3000 MD0000200380
Clear Choice HMO HSA Bronze 5900 MD0000200387
Clear Choice HMO HSA Bronze 6300 MD0000200388
Clear Choice HMO HSA Bronze 7000 MD0000200389
Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 MD0000200393
Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 MD0000200394
Clear Choice HMO Silver 5500 MD0000200407
Clear Choice HMO Silver 6000 MD0000200409
Clear Choice HMO Bronze 7500 MD0000200411
Clear Choice HMO Bronze 8000 MD0000200412
Clear Choice HMO Bronze 9100 MD0000200413
Clear Choice HMO Catastrophic 9100 MD0000200414
Clear Choice Maine's Choice Plus HMO Gold 2500 MD0000200432
Clear Choice Maine's Choice Plus HMO Silver 3000 MD0000200434
Clear Choice Maine's Choice Plus HMO Silver 3500 MD0000200436
Clear Choice Maine's Choice Plus HMO Silver 4200 MD0000200437
Clear Choice Maine's Choice Plus HMO Silver 6000 MD0000200439
Clear Choice Maine's Choice Plus HMO Silver 5500 MD0000200441
Clear Choice Maine's Choice Plus HMO Bronze 7500 MD0000200443
Clear Choice Maine's Choice Plus HMO Bronze 8000 MD0000200444
HMO Silver 6800 MD0000200479
HMO - ON EXCHANGE without Dental - AI/AN - Limited SOB SBC
Clear Choice HMO Gold 1500 CSR LCS MD0000200368
Clear Choice HMO Gold 2500 CSR LCS MD0000200369
Clear Choice HMO Silver 3000 CSR LCS MD0000200372
Clear Choice HMO Silver 3500 CSR LCS MD0000200374
Clear Choice HMO Silver 4200 CSR LCS MD0000200375
Clear Choice Maine's Choice Plus HMO HSA Silver 3000 CSR LCS MD0000200380
Clear Choice HMO HSA Bronze 5900 CSR LCS MD0000200387
Clear Choice HMO HSA Bronze 6300 CSR LCS MD0000200388
Clear Choice HMO HSA Bronze 7000 CSR LCS MD0000200389
Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 CSR LCS MD0000200393
Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 CSR LCS MD0000200394
Clear Choice HMO Silver 5500 CSR LCS MD0000200407
Clear Choice HMO Silver 6000 CSR LCS MD0000200409
Clear Choice HMO Bronze 7500 CSR LCS MD0000200411
Clear Choice HMO Bronze 8000 CSR LCS MD0000200412
Clear Choice HMO Bronze 9100 CSR LCS MD0000200413
Clear Choice Maine's Choice Plus HMO Gold 2500 CSR LCS MD0000200432
Clear Choice Maine's Choice Plus HMO Silver 3000 CSR LCS MD0000200434
Clear Choice Maine's Choice Plus HMO Silver 3500 CSR LCS MD0000200436
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR LCS MD0000200437
Clear Choice Maine's Choice Plus HMO Silver 6000 CSR LCS MD0000200439
Clear Choice Maine's Choice Plus HMO Silver 5500 CSR LCS MD0000200441
Clear Choice Maine's Choice Plus HMO Bronze 7500 CSR LCS MD0000200443
Clear Choice Maine's Choice Plus HMO Bronze 8000 CSR LCS MD0000200444
HMO Silver 6800 CSR LCS MD0000200479
HMO - ON EXCHANGE without Dental - AI/AN - $0 SOB SBC
HMO CSR 100 MD0000200371
HMO CSR 100 MD0000200371
HMO CSR 100 MD0000200371
HMO CSR 100 MD0000200371
HMO CSR 100 MD0000200371
Maine's Choice Plus HMO CSR 100 MD0000200381
HMO CSR 100 MD0000200371
HMO CSR 100 MD0000200371
HMO CSR 100 MD0000200371
Maine's Choice Plus HMO CSR 100 MD0000200381
Maine's Choice Plus HMO CSR 100 MD0000200381
HMO CSR 100 MD0000200371
HMO CSR 100 MD0000200371
HMO CSR 100 MD0000200371
HMO CSR 100 MD0000200371
HMO CSR 100 MD0000200371
Maine's Choice Plus HMO CSR 100 MD0000200381
Maine's Choice Plus HMO CSR 100 MD0000200381
Maine's Choice Plus HMO CSR 100 MD0000200381
Maine's Choice Plus HMO CSR 100 MD0000200381
Maine's Choice Plus HMO CSR 100 MD0000200381
Maine's Choice Plus HMO CSR 100 MD0000200381
Maine's Choice Plus HMO CSR 100 MD0000200381
Maine's Choice Plus HMO CSR 100 MD0000200381
HMO CSR 100 MD0000200371
PPO - OFF EXCHANGE with Dental SOB SBC
Clear Choice PPO HSA Silver 3000 MD0000200395
Clear Choice PPO HSA Silver 3500 MD0000200396
Clear Choice PPO HSA Silver 4000 MD0000200397
Clear Choice PPO HSA Silver 4500 MD0000200398
Clear Choice PPO HSA Bronze 5200 MD0000200399
Clear Choice PPO HSA Bronze 5900 MD0000200400
Clear Choice PPO HSA Bronze 6300 MD0000200401
Clear Choice PPO HSA Bronze 7000 MD0000200402
Clear Choice PPO Gold 1500 MD0000200421
Clear Choice PPO Gold 2500 MD0000200422
Clear Choice PPO Silver 3000 MD0000200423
Clear Choice PPO Silver 3500 MD0000200424
Clear Choice PPO Silver 4200 MD0000200425
Clear Choice PPO Silver 6000 MD0000200426
Clear Choice PPO Silver 5500 MD0000200427
Clear Choice PPO Bronze 7500 MD0000200428
Clear Choice PPO Bronze 8000 MD0000200429
Clear Choice PPO Bronze 9100 MD0000200430
PPO Gold 2700 MD0000200478
PPO Silver 6800 MD0000200481
PPO - OFF EXCHANGE without Dental SOB SBC
Clear Choice PPO HSA Silver 3000 MD0000200395
Clear Choice PPO HSA Silver 3500 MD0000200396
Clear Choice PPO HSA Silver 4000 MD0000200397
Clear Choice PPO HSA Silver 4500 MD0000200398
Clear Choice PPO HSA Bronze 5200 MD0000200399
Clear Choice PPO HSA Bronze 5900 MD0000200400
Clear Choice PPO HSA Bronze 6300 MD0000200401
Clear Choice PPO HSA Bronze 7000 MD0000200402
Clear Choice PPO Gold 1500 MD0000200421
Clear Choice PPO Gold 2500 MD0000200422
Clear Choice PPO Silver 3000 MD0000200423
Clear Choice PPO Silver 3500 MD0000200424
Clear Choice PPO Silver 4200 MD0000200425
Clear Choice PPO Silver 6000 MD0000200426
Clear Choice PPO Silver 5500 MD0000200427
Clear Choice PPO Bronze 7500 MD0000200428
Clear Choice PPO Bronze 8000 MD0000200429
Clear Choice PPO Bronze 9100 MD0000200430
PPO Gold 2700 MD0000200478
PPO Silver 6800 MD0000200481
POS - OFF EXCHANGE with Dental SOB SBC
Clear Choice POS HSA Silver 3500 MD0000200403
Clear Choice POS HSA Silver 4500 MD0000200404
Clear Choice POS HSA Bronze 6300 MD0000200405
Clear Choice POS HSA Bronze 7000 MD0000200406
Clear Choice POS Gold 2500 MD0000200415
Clear Choice POS Silver 3000 MD0000200416
Clear Choice POS Silver 3500 MD0000200417
Clear Choice POS Silver 4200 MD0000200418
Clear Choice POS Silver 6000 MD0000200419
Clear Choice POS Silver 5500 MD0000200420
POS - OFF EXCHANGE without Dental SOB SBC
Clear Choice POS HSA Silver 3500 MD0000200403
Clear Choice POS HSA Silver 4500 MD0000200404
Clear Choice POS HSA Bronze 6300 MD0000200405
Clear Choice POS HSA Bronze 7000 MD0000200406
Clear Choice POS Gold 2500 MD0000200415
Clear Choice POS Silver 3000 MD0000200416
Clear Choice POS Silver 3500 MD0000200417
Clear Choice POS Silver 4200 MD0000200418
Clear Choice POS Silver 6000 MD0000200419
Clear Choice POS Silver 5500 MD0000200420
HMO - ON EXCHANGE without Dental - CSR - 73% SOB SBC
Clear Choice HMO Silver 3500 CSR 73 MD0000200445
Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 73 MD0000200448
Clear Choice HMO Silver 5500 CSR 73 MD0000200451
Clear Choice Maine's Choice Plus HMO Silver 5500 CSR 73 MD0000200455
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 73 MD0000200458
Clear Choice HMO Silver 4200 CSR 73 MD0000200461
Clear Choice HMO Silver 3000 CSR 73 MD0000200464
Clear Choice Maine's Choice Plus HMO Silver 3000 CSR 73 MD0000200467
Clear Choice HMO Silver 6000 CSR 73 MD0000200470
Clear Choice Maine's Choice Plus HMO Silver 6000 CSR 73 MD0000200473
HMO Silver 6800 CSR 73 MD0000200483
Clear Choice Maine's Choice Plus HMO HSA Silver 3000 CSR 73 MD0000200486
HMO - ON EXCHANGE without Dental - CSR - 87% SOB SBC
Clear Choice HMO Silver 3500 CSR 87 MD0000200446
Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 87 MD0000200449
Clear Choice HMO Silver 5500 CSR 87 MD0000200452
Clear Choice Maine's Choice Plus HMO Silver 5500 CSR 87 MD0000200456
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 87 MD0000200459
Clear Choice HMO Silver 4200 CSR 87 MD0000200462
Clear Choice HMO Silver 3000 CSR 87 MD0000200465
Clear Choice Maine's Choice Plus HMO Silver 3000 CSR 87 MD0000200468