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
HMO Bronze 7500 Clear Choice MD0000100380
HMO Bronze 8700 Clear Choice MD0000100382
HMO HSA Bronze 5900 Clear Choice MD0000100384
HMO HSA Bronze 7000 Clear Choice MD0000100386
HMO HSA Silver 3500 Clear Choice MD0000100387
HMO HSA Silver 4500 Clear Choice MD0000100388
Maine's Choice Plus℠ HMO Gold 1500 Clear Choice MD0000100390
Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice MD0000100393
Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice MD0000100395
Maine's Choice Plus℠ HMO HSA Silver 3500 Clear Choice MD0000100396
Maine's Choice Plus℠ HMO HSA Silver 4500 Clear Choice MD0000100397
HMO Catastrophic 8700 Clear Choice MD0000100398
HMO Silver 3500 Clear Choice MD0000100399
Maine's Choice Plus℠ HMO Silver 3500 Clear Choice MD0000100405
HMO Silver 5500 Clear Choice MD0000100411
Maine's Choice Plus℠ HMO Silver 5500 Clear Choice MD0000100416
HMO Bronze 8000 MD0000100463
Maine's Choice Plus℠ HMO HSA Bronze 6250 MD0000100464
Maine's Choice Plus℠ HMO Silver 4250 MD0000100470
HMO - OFF EXCHANGE without Dental SOB SBC
HMO Gold 1500 Clear Choice MD0000100377
HMO Bronze 7500 Clear Choice MD0000100380
HMO Bronze 8700 Clear Choice MD0000100382
HMO HSA Bronze 5900 Clear Choice MD0000100384
HMO HSA Bronze 7000 Clear Choice MD0000100386
HMO HSA Silver 3500 Clear Choice MD0000100387
HMO HSA Silver 4500 Clear Choice MD0000100388
Maine's Choice Plus℠ HMO Gold 1500 Clear Choice MD0000100390
Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice MD0000100393
Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice MD0000100395
Maine's Choice Plus℠ HMO HSA Silver 3500 Clear Choice MD0000100396
Maine's Choice Plus℠ HMO HSA Silver 4500 Clear Choice MD0000100397
HMO Catastrophic 8700 Clear Choice MD0000100398
HMO Silver 3500 Clear Choice MD0000100401
Maine's Choice Plus℠ HMO Silver 3500 Clear Choice MD0000100407
HMO Silver 5500 Clear Choice MD0000100575
Maine's Choice Plus℠ HMO Silver 5500 Clear Choice MD0000100576
HMO Bronze 8000 MD0000100463
Maine's Choice Plus℠ HMO HSA Bronze 6250 MD0000100464
Maine's Choice Plus℠ HMO Silver 4250 MD0000100471
HMO - ON EXCHANGE without Dental SOB SBC
HMO Gold 1500 Clear Choice MD0000100377
HMO Bronze 7500 Clear Choice MD0000100380
HMO Bronze 8700 Clear Choice MD0000100382
HMO HSA Bronze 5900 Clear Choice MD0000100384
HMO HSA Bronze 7000 Clear Choice MD0000100386
Maine's Choice Plus℠ HMO Gold 1500 Clear Choice MD0000100390
Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice MD0000100393
Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice MD0000100395
HMO Catastrophic 8700 Clear Choice MD0000100398
HMO Silver 3500 Clear Choice MD0000100401
Maine's Choice Plus℠ HMO Silver 3500 Clear Choice MD0000100407
HMO Silver 5500 Clear Choice MD0000100575
Maine's Choice Plus℠ HMO Silver 5500 Clear Choice MD0000100576
HMO Bronze 8000 MD0000100463
Maine's Choice Plus℠ HMO HSA Bronze 6250 MD0000100464
Maine's Choice Plus℠ HMO Silver 4250 MD0000100471
HMO - ON EXCHANGE without Dental - AI/AN - Limited SOB SBC
HMO Gold 1500 Clear Choice MD0000100377
HMO Bronze 7500 Clear Choice MD0000100380
HMO Bronze 8700 Clear Choice MD0000100382
HMO HSA Bronze 5900 Clear Choice MD0000100384
HMO HSA Bronze 7000 Clear Choice MD0000100386
Maine's Choice Plus℠ HMO Gold 1500 Clear Choice MD0000100390
Maine's Choice Plus℠ HMO Bronze 7500 Clear Choice MD0000100393
Maine's Choice Plus℠ HMO HSA Bronze 5900 Clear Choice MD0000100395
HMO Silver 3500 Clear Choice MD0000100401
Maine's Choice Plus℠ HMO Silver 3500 Clear Choice MD0000100407
HMO Silver 5500 Clear Choice MD0000100575
Maine's Choice Plus℠ HMO Silver 5500 Clear Choice MD0000100576
HMO Bronze 8000 MD0000100463
Maine's Choice Plus℠ HMO HSA Bronze 6250 MD0000100464
Maine's Choice Plus℠ HMO Silver 4250 MD0000100471
HMO - ON EXCHANGE without Dental - AI/AN - $0 SOB SBC
HMO MD0000100378
HMO MD0000100378
HMO MD0000100378
HMO MD0000100378
HMO MD0000100378
Maine's Choice Plus℠ HMO MD0000100391
Maine's Choice Plus℠ HMO MD0000100391
Maine's Choice Plus℠ HMO MD0000100391
HMO MD0000100378
Maine's Choice Plus℠ HMO MD0000100391
HMO MD0000100378
Maine's Choice Plus℠ HMO MD0000100391
HMO MD0000100378
Maine's Choice Plus℠ HMO MD0000100391
Maine's Choice Plus℠ HMO MD0000100391
HMO - ON EXCHANGE without Dental - CSR - 94% SOB SBC
HMO Silver 3500 CSR94 Clear Choice MD0000100402
Maine's Choice Plus℠ HMO Silver 3500 CSR94 Clear Choice MD0000100408
HMO Silver 5500 CSR94 Clear Choice MD0000100413
Maine's Choice Plus℠ HMO Silver 5500 CSR94 Clear Choice MD0000100418
Maine's Choice Plus℠ HMO Silver 4250 CSR94 MD0000100472
HMO - ON EXCHANGE without Dental - CSR - 87% SOB SBC
HMO Silver 3500 CSR87 Clear Choice MD0000100403
Maine's Choice Plus℠ HMO Silver 3500 CSR87 Clear Choice MD0000100409
HMO Silver 5500 CSR87 Clear Choice MD0000100414
Maine's Choice Plus℠ HMO Silver 5500 CSR87 Clear Choice MD0000100419
Maine's Choice Plus℠ HMO Silver 4250 CSR87 MD0000100473
HMO - ON EXCHANGE without Dental - CSR - 73% SOB SBC
HMO Silver 3500 CSR73 Clear Choice MD0000100404
Maine's Choice Plus℠ HMO Silver 3500 CSR73 Clear Choice MD0000100410
HMO Silver 5500 CSR73 Clear Choice MD0000100415
Maine's Choice Plus℠ HMO Silver 5500 CSR73 Clear Choice MD0000100420
Maine's Choice Plus℠ HMO Silver 4250 CSR73 MD0000100474