Schedules of Benefits and SBCs: Maine

Individual Market effective 1/1/22

HMO - OFF EXCHANGE with Dental	SOB	SBC
HMO Gold 1500 Clear Choice MD0000100377	Show HMO Gold 1500 Clear Choice SOB	Show HMO Gold 1500 Clear Choice SBC

RX: RX0000100263 Vision: VS0000100127
HMO Bronze 7500 Clear Choice MD0000100380	Show HMO Bronze 7500 Clear Choice SOB	Show HMO Bronze 7500 Clear Choice SBC

RX: RX0000100265 Vision: VS0000100130
HMO Bronze 8700 Clear Choice MD0000100382	Show HMO Bronze 8700 Clear Choice SOB	Show HMO Bronze 8700 Clear Choice SBC

RX: RX0000100266 Vision: VS0000100130
HMO HSA Bronze 5900 Clear Choice MD0000100384	Show HMO HSA Bronze 5900 Clear Choice SOB	Show HMO HSA Bronze 5900 Clear Choice SBC

RX: RX0000100267 Vision: VS0000100149
HMO HSA Bronze 7000 Clear Choice MD0000100386	Show HMO HSA Bronze 7000 Clear Choice SOB	Show HMO HSA Bronze 7000 Clear Choice SBC

RX: RX0000100268 Vision: VS0000100131
HMO HSA Silver 3500 Clear Choice MD0000100387	Show HMO HSA Silver 3500 Clear Choice SOB	Show HMO HSA Silver 3500 Clear Choice SBC

RX: RX0000100269 Vision: VS0000100131
HMO HSA Silver 4500 Clear Choice MD0000100388	Show HMO HSA Silver 4500 Clear Choice SOB	Show HMO HSA Silver 4500 Clear Choice SBC

RX: RX0000100270 Vision: VS0000100131
Maine's Choice Plus℠ HMO Gold 1500 Clear Choice MD0000100390	Show Maine's Choice Plus℠ HMO Gold 1500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Gold 1500 Clear Choice SBC

RX: RX0000100271 Vision: VS0000100127
Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice MD0000100393	Show Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice SBC

RX: RX0000100272 Vision: VS0000100130
Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice MD0000100395	Show Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice SOB	Show Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice SBC

RX: RX0000100273 Vision: VS0000100149
Maine's Choice Plus℠ HMO HSA Silver 3500 Clear Choice MD0000100396	Show Maine's Choice Plus℠ HMO HSA Silver 3500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO HSA Silver 3500 Clear Choice SBC

RX: RX0000100274 Vision: VS0000100131
Maine's Choice Plus℠ HMO HSA Silver 4500 Clear Choice MD0000100397	Show Maine's Choice Plus℠ HMO HSA Silver 4500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO HSA Silver 4500 Clear Choice SBC

RX: RX0000100275 Vision: VS0000100131
HMO Catastrophic 8700 Clear Choice MD0000100398	Show HMO Catastrophic 8700 Clear Choice SOB	Show HMO Catastrophic 8700 Clear Choice SBC

RX: RX0000100276 Vision: VS0000100135
HMO Silver 3500 Clear Choice MD0000100399	Show HMO Silver 3500 Clear Choice SOB	Show HMO Silver 3500 Clear Choice SBC

RX: RX0000100277 Vision: VS0000100130
Maine's Choice Plus℠ HMO Silver 3500 Clear Choice MD0000100405	Show Maine's Choice Plus℠ HMO Silver 3500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 3500 Clear Choice SBC

RX: RX0000100281 Vision: VS0000100130
HMO Silver 5500 Clear Choice MD0000100411	Show HMO Silver 5500 Clear Choice SOB	Show HMO Silver 5500 Clear Choice SBC

RX: RX0000100285 Vision: VS0000100147
Maine's Choice Plus℠ HMO Silver 5500 Clear Choice MD0000100416	Show Maine's Choice Plus℠ HMO Silver 5500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 5500 Clear Choice SBC

RX: RX0000100289 Vision: VS0000100147
HMO Bronze 8000 MD0000100463	Show HMO Bronze 8000 SOB	Show HMO Bronze 8000 SBC

RX: RX0000100312 Vision: VS0000100130
Maine's Choice Plus℠ HMO HSA Bronze 6250 MD0000100464	Show Maine's Choice Plus℠ HMO HSA Bronze 6250 SOB	Show Maine's Choice Plus℠ HMO HSA Bronze 6250 SBC

RX: RX0000100313 Vision: VS0000100131
Maine's Choice Plus℠ HMO Silver 4250 MD0000100470	Show Maine's Choice Plus℠ HMO Silver 4250 SOB	Show Maine's Choice Plus℠ HMO Silver 4250 SBC

RX: RX0000100296 Vision: VS0000100130

HMO - OFF EXCHANGE without Dental	SOB	SBC
HMO Gold 1500 Clear Choice MD0000100377	Show HMO Gold 1500 Clear Choice SOB	Show HMO Gold 1500 Clear Choice SBC

RX: RX0000100263 Vision: VS0000100127
HMO Bronze 7500 Clear Choice MD0000100380	Show HMO Bronze 7500 Clear Choice SOB	Show HMO Bronze 7500 Clear Choice SBC

RX: RX0000100265 Vision: VS0000100130
HMO Bronze 8700 Clear Choice MD0000100382	Show HMO Bronze 8700 Clear Choice SOB	Show HMO Bronze 8700 Clear Choice SBC

RX: RX0000100266 Vision: VS0000100130
HMO HSA Bronze 5900 Clear Choice MD0000100384	Show HMO HSA Bronze 5900 Clear Choice SOB	Show HMO HSA Bronze 5900 Clear Choice SBC

RX: RX0000100267 Vision: VS0000100149
HMO HSA Bronze 7000 Clear Choice MD0000100386	Show HMO HSA Bronze 7000 Clear Choice SOB	Show HMO HSA Bronze 7000 Clear Choice SBC

RX: RX0000100268 Vision: VS0000100131
HMO HSA Silver 3500 Clear Choice MD0000100387	Show HMO HSA Silver 3500 Clear Choice SOB	Show HMO HSA Silver 3500 Clear Choice SBC

RX: RX0000100269 Vision: VS0000100131
HMO HSA Silver 4500 Clear Choice MD0000100388	Show HMO HSA Silver 4500 Clear Choice SOB	Show HMO HSA Silver 4500 Clear Choice SBC

RX: RX0000100270 Vision: VS0000100131
Maine's Choice Plus℠ HMO Gold 1500 Clear Choice MD0000100390	Show Maine's Choice Plus℠ HMO Gold 1500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Gold 1500 Clear Choice SBC

RX: RX0000100271 Vision: VS0000100127
Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice MD0000100393	Show Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice SBC

RX: RX0000100272 Vision: VS0000100130
Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice MD0000100395	Show Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice SOB	Show Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice SBC

RX: RX0000100273 Vision: VS0000100149
Maine's Choice Plus℠ HMO HSA Silver 3500 Clear Choice MD0000100396	Show Maine's Choice Plus℠ HMO HSA Silver 3500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO HSA Silver 3500 Clear Choice SBC

RX: RX0000100274 Vision: VS0000100131
Maine's Choice Plus℠ HMO HSA Silver 4500 Clear Choice MD0000100397	Show Maine's Choice Plus℠ HMO HSA Silver 4500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO HSA Silver 4500 Clear Choice SBC

RX: RX0000100275 Vision: VS0000100131
HMO Catastrophic 8700 Clear Choice MD0000100398	Show HMO Catastrophic 8700 Clear Choice SOB	Show HMO Catastrophic 8700 Clear Choice SBC

RX: RX0000100276 Vision: VS0000100135
HMO Silver 3500 Clear Choice MD0000100401	Show HMO Silver 3500 Clear Choice SOB	Show HMO Silver 3500 Clear Choice SBC

RX: RX0000100277 Vision: VS0000100130
Maine's Choice Plus℠ HMO Silver 3500 Clear Choice MD0000100407	Show Maine's Choice Plus℠ HMO Silver 3500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 3500 Clear Choice SBC

RX: RX0000100281 Vision: VS0000100130
HMO Silver 5500 Clear Choice MD0000100575	Show HMO Silver 5500 Clear Choice SOB	Show HMO Silver 5500 Clear Choice SBC

RX: RX0000100285 Vision: VS0000100147
Maine's Choice Plus℠ HMO Silver 5500 Clear Choice MD0000100576	Show Maine's Choice Plus℠ HMO Silver 5500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 5500 Clear Choice SBC

RX: RX0000100289 Vision: VS0000100147
HMO Bronze 8000 MD0000100463	Show HMO Bronze 8000 SOB	Show HMO Bronze 8000 SBC

RX: RX0000100312 Vision: VS0000100130
Maine's Choice Plus℠ HMO HSA Bronze 6250 MD0000100464	Show Maine's Choice Plus℠ HMO HSA Bronze 6250 SOB	Show Maine's Choice Plus℠ HMO HSA Bronze 6250 SBC

RX: RX0000100313 Vision: VS0000100131
Maine's Choice Plus℠ HMO Silver 4250 MD0000100471	Show Maine's Choice Plus℠ HMO Silver 4250 SOB	Show Maine's Choice Plus℠ HMO Silver 4250 SBC

RX: RX0000100296 Vision: VS0000100130

HMO - ON EXCHANGE without Dental	SOB	SBC
HMO Gold 1500 Clear Choice MD0000100377	Show HMO Gold 1500 Clear Choice SOB	Show HMO Gold 1500 Clear Choice SBC

RX: RX0000100263 Vision: VS0000100127
HMO Bronze 7500 Clear Choice MD0000100380	Show HMO Bronze 7500 Clear Choice SOB	Show HMO Bronze 7500 Clear Choice SBC

RX: RX0000100265 Vision: VS0000100130
HMO Bronze 8700 Clear Choice MD0000100382	Show HMO Bronze 8700 Clear Choice SOB	Show HMO Bronze 8700 Clear Choice SBC

RX: RX0000100266 Vision: VS0000100130
HMO HSA Bronze 5900 Clear Choice MD0000100384	Show HMO HSA Bronze 5900 Clear Choice SOB	Show HMO HSA Bronze 5900 Clear Choice SBC

RX: RX0000100267 Vision: VS0000100149
HMO HSA Bronze 7000 Clear Choice MD0000100386	Show HMO HSA Bronze 7000 Clear Choice SOB	Show HMO HSA Bronze 7000 Clear Choice SBC

RX: RX0000100268 Vision: VS0000100131
Maine's Choice Plus℠ HMO Gold 1500 Clear Choice MD0000100390	Show Maine's Choice Plus℠ HMO Gold 1500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Gold 1500 Clear Choice SBC

RX: RX0000100271 Vision: VS0000100127
Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice MD0000100393	Show Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice SBC

RX: RX0000100272 Vision: VS0000100130
Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice MD0000100395	Show Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice SOB	Show Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice SBC

RX: RX0000100273 Vision: VS0000100149
HMO Catastrophic 8700 Clear Choice MD0000100398	Show HMO Catastrophic 8700 Clear Choice SOB	Show HMO Catastrophic 8700 Clear Choice SBC

RX: RX0000100276 Vision: VS0000100135
HMO Silver 3500 Clear Choice MD0000100401	Show HMO Silver 3500 Clear Choice SOB	Show HMO Silver 3500 Clear Choice SBC

RX: RX0000100277 Vision: VS0000100130
Maine's Choice Plus℠ HMO Silver 3500 Clear Choice MD0000100407	Show Maine's Choice Plus℠ HMO Silver 3500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 3500 Clear Choice SBC

RX: RX0000100281 Vision: VS0000100130
HMO Silver 5500 Clear Choice MD0000100575	Show HMO Silver 5500 Clear Choice SOB	Show HMO Silver 5500 Clear Choice SBC

RX: RX0000100285 Vision: VS0000100147
Maine's Choice Plus℠ HMO Silver 5500 Clear Choice MD0000100576	Show Maine's Choice Plus℠ HMO Silver 5500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 5500 Clear Choice SBC

RX: RX0000100289 Vision: VS0000100147
HMO Bronze 8000 MD0000100463	Show HMO Bronze 8000 SOB	Show HMO Bronze 8000 SBC

RX: RX0000100312 Vision: VS0000100130
Maine's Choice Plus℠ HMO HSA Bronze 6250 MD0000100464	Show Maine's Choice Plus℠ HMO HSA Bronze 6250 SOB	Show Maine's Choice Plus℠ HMO HSA Bronze 6250 SBC

RX: RX0000100313 Vision: VS0000100131
Maine's Choice Plus℠ HMO Silver 4250 MD0000100471	Show Maine's Choice Plus℠ HMO Silver 4250 SOB	Show Maine's Choice Plus℠ HMO Silver 4250 SBC

RX: RX0000100296 Vision: VS0000100130

HMO - ON EXCHANGE without Dental - AI/AN - Limited	SOB	SBC
HMO Gold 1500 Clear Choice MD0000100377	Show HMO Gold 1500 Clear Choice SOB	Show HMO Gold 1500 Clear Choice SBC

RX: RX0000100263 Vision: VS0000100127
HMO Bronze 7500 Clear Choice MD0000100380	Show HMO Bronze 7500 Clear Choice SOB	Show HMO Bronze 7500 Clear Choice SBC

RX: RX0000100265 Vision: VS0000100130
HMO Bronze 8700 Clear Choice MD0000100382	Show HMO Bronze 8700 Clear Choice SOB	Show HMO Bronze 8700 Clear Choice SBC

RX: RX0000100266 Vision: VS0000100130
HMO HSA Bronze 5900 Clear Choice MD0000100384	Show HMO HSA Bronze 5900 Clear Choice SOB	Show HMO HSA Bronze 5900 Clear Choice SBC

RX: RX0000100267 Vision: VS0000100149
HMO HSA Bronze 7000 Clear Choice MD0000100386	Show HMO HSA Bronze 7000 Clear Choice SOB	Show HMO HSA Bronze 7000 Clear Choice SBC

RX: RX0000100268 Vision: VS0000100131
Maine's Choice Plus℠ HMO Gold 1500 Clear Choice MD0000100390	Show Maine's Choice Plus℠ HMO Gold 1500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Gold 1500 Clear Choice SBC

RX: RX0000100271 Vision: VS0000100127
Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice MD0000100393	Show Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice SBC

RX: RX0000100272 Vision: VS0000100130
Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice MD0000100395	Show Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice SOB	Show Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice SBC

RX: RX0000100273 Vision: VS0000100149
HMO Silver 3500 Clear Choice MD0000100401	Show HMO Silver 3500 Clear Choice SOB	Show HMO Silver 3500 Clear Choice SBC

RX: RX0000100277 Vision: VS0000100130
Maine's Choice Plus℠ HMO Silver 3500 Clear Choice MD0000100407	Show Maine's Choice Plus℠ HMO Silver 3500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 3500 Clear Choice SBC

RX: RX0000100281 Vision: VS0000100130
HMO Silver 5500 Clear Choice MD0000100575	Show HMO Silver 5500 Clear Choice SOB	Show HMO Silver 5500 Clear Choice SBC

RX: RX0000100285 Vision: VS0000100147
Maine's Choice Plus℠ HMO Silver 5500 Clear Choice MD0000100576	Show Maine's Choice Plus℠ HMO Silver 5500 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 5500 Clear Choice SBC

RX: RX0000100289 Vision: VS0000100147
HMO Bronze 8000 MD0000100463	Show HMO Bronze 8000 SOB	Show HMO Bronze 8000 SBC

RX: RX0000100312 Vision: VS0000100130
Maine's Choice Plus℠ HMO HSA Bronze 6250 MD0000100464	Show Maine's Choice Plus℠ HMO HSA Bronze 6250 SOB	Show Maine's Choice Plus℠ HMO HSA Bronze 6250 SBC

RX: RX0000100313 Vision: VS0000100131
Maine's Choice Plus℠ HMO Silver 4250 MD0000100471	Show Maine's Choice Plus℠ HMO Silver 4250 SOB	Show Maine's Choice Plus℠ HMO Silver 4250 SBC

RX: RX0000100296 Vision: VS0000100130

HMO - ON EXCHANGE without Dental - AI/AN - $0	SOB	SBC
HMO MD0000100378	Show HMO SOB	Show HMO SBC

RX: RX0000100264 Vision: VS0000100128
HMO MD0000100378	Show HMO SOB	Show HMO SBC

RX: RX0000100264 Vision: VS0000100128
HMO MD0000100378	Show HMO SOB	Show HMO SBC

RX: RX0000100264 Vision: VS0000100128
HMO MD0000100378	Show HMO SOB	Show HMO SBC

RX: RX0000100264 Vision: VS0000100128
HMO MD0000100378	Show HMO SOB	Show HMO SBC

RX: RX0000100264 Vision: VS0000100128
Maine's Choice Plus℠ HMO MD0000100391	Show Maine's Choice Plus℠ HMO SOB	Show Maine's Choice Plus℠ HMO SBC

RX: RX0000100264 Vision: VS0000100128
Maine's Choice Plus℠ HMO MD0000100391	Show Maine's Choice Plus℠ HMO SOB	Show Maine's Choice Plus℠ HMO SBC

RX: RX0000100264 Vision: VS0000100128
Maine's Choice Plus℠ HMO MD0000100391	Show Maine's Choice Plus℠ HMO SOB	Show Maine's Choice Plus℠ HMO SBC

RX: RX0000100264 Vision: VS0000100128
HMO MD0000100378	Show HMO SOB	Show HMO SBC

RX: RX0000100264 Vision: VS0000100128
Maine's Choice Plus℠ HMO MD0000100391	Show Maine's Choice Plus℠ HMO SOB	Show Maine's Choice Plus℠ HMO SBC

RX: RX0000100264 Vision: VS0000100128
HMO MD0000100378	Show HMO SOB	Show HMO SBC

RX: RX0000100264 Vision: VS0000100128
Maine's Choice Plus℠ HMO MD0000100391	Show Maine's Choice Plus℠ HMO SOB	Show Maine's Choice Plus℠ HMO SBC

RX: RX0000100264 Vision: VS0000100128
HMO MD0000100378	Show HMO SOB	Show HMO SBC

RX: RX0000100264 Vision: VS0000100128
Maine's Choice Plus℠ HMO MD0000100391	Show Maine's Choice Plus℠ HMO SOB	Show Maine's Choice Plus℠ HMO SBC

RX: RX0000100264 Vision: VS0000100128
Maine's Choice Plus℠ HMO MD0000100391	Show Maine's Choice Plus℠ HMO SOB	Show Maine's Choice Plus℠ HMO SBC

RX: RX0000100264 Vision: VS0000100128

HMO - ON EXCHANGE without Dental - CSR - 94%	SOB	SBC
HMO Silver 3500 CSR94 Clear Choice MD0000100402	Show HMO Silver 3500 CSR94 Clear Choice SOB	Show HMO Silver 3500 CSR94 Clear Choice SBC

RX: RX0000100278 Vision: VS0000100136
Maine's Choice Plus℠ HMO Silver 3500 CSR94 Clear Choice MD0000100408	Show Maine's Choice Plus℠ HMO Silver 3500 CSR94 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 3500 CSR94 Clear Choice SBC

RX: RX0000100282 Vision: VS0000100132
HMO Silver 5500 CSR94 Clear Choice MD0000100413	Show HMO Silver 5500 CSR94 Clear Choice SOB	Show HMO Silver 5500 CSR94 Clear Choice SBC

RX: RX0000100286 Vision: VS0000100132
Maine's Choice Plus℠ HMO Silver 5500 CSR94 Clear Choice MD0000100418	Show Maine's Choice Plus℠ HMO Silver 5500 CSR94 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 5500 CSR94 Clear Choice SBC

RX: RX0000100290 Vision: VS0000100142
Maine's Choice Plus℠ HMO Silver 4250 CSR94 MD0000100472	Show Maine's Choice Plus℠ HMO Silver 4250 CSR94 SOB	Show Maine's Choice Plus℠ HMO Silver 4250 CSR94 SBC

RX: RX0000100319 Vision: VS0000100132

HMO - ON EXCHANGE without Dental - CSR - 87%	SOB	SBC
HMO Silver 3500 CSR87 Clear Choice MD0000100403	Show HMO Silver 3500 CSR87 Clear Choice SOB	Show HMO Silver 3500 CSR87 Clear Choice SBC

RX: RX0000100279 Vision: VS0000100137
Maine's Choice Plus℠ HMO Silver 3500 CSR87 Clear Choice MD0000100409	Show Maine's Choice Plus℠ HMO Silver 3500 CSR87 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 3500 CSR87 Clear Choice SBC

RX: RX0000100283 Vision: VS0000100140
HMO Silver 5500 CSR87 Clear Choice MD0000100414	Show HMO Silver 5500 CSR87 Clear Choice SOB	Show HMO Silver 5500 CSR87 Clear Choice SBC

RX: RX0000100287 Vision: VS0000100133
Maine's Choice Plus℠ HMO Silver 5500 CSR87 Clear Choice MD0000100419	Show Maine's Choice Plus℠ HMO Silver 5500 CSR87 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 5500 CSR87 Clear Choice SBC

RX: RX0000100291 Vision: VS0000100140
Maine's Choice Plus℠ HMO Silver 4250 CSR87 MD0000100473	Show Maine's Choice Plus℠ HMO Silver 4250 CSR87 SOB	Show Maine's Choice Plus℠ HMO Silver 4250 CSR87 SBC

RX: RX0000100320 Vision: VS0000100140

HMO - ON EXCHANGE without Dental - CSR - 73%	SOB	SBC
HMO Silver 3500 CSR73 Clear Choice MD0000100404	Show HMO Silver 3500 CSR73 Clear Choice SOB	Show HMO Silver 3500 CSR73 Clear Choice SBC

RX: RX0000100280 Vision: VS0000100161
Maine's Choice Plus℠ HMO Silver 3500 CSR73 Clear Choice MD0000100410	Show Maine's Choice Plus℠ HMO Silver 3500 CSR73 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 3500 CSR73 Clear Choice SBC

RX: RX0000100284 Vision: VS0000100141
HMO Silver 5500 CSR73 Clear Choice MD0000100415	Show HMO Silver 5500 CSR73 Clear Choice SOB	Show HMO Silver 5500 CSR73 Clear Choice SBC

RX: RX0000100288 Vision: VS0000100162
Maine's Choice Plus℠ HMO Silver 5500 CSR73 Clear Choice MD0000100420	Show Maine's Choice Plus℠ HMO Silver 5500 CSR73 Clear Choice SOB	Show Maine's Choice Plus℠ HMO Silver 5500 CSR73 Clear Choice SBC

RX: RX0000100292 Vision: VS0000100141
Maine's Choice Plus℠ HMO Silver 4250 CSR73 MD0000100474	Show Maine's Choice Plus℠ HMO Silver 4250 CSR73 SOB	Show Maine's Choice Plus℠ HMO Silver 4250 CSR73 SBC

RX: RX0000100321 Vision: VS0000100141

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Individual Market effective 1/1/22