Schedules of Benefits and SBCs: Massachusetts

Individual Market effective 1/1/21

HMO - ON EXCHANGE with Dental SOB SBC
Standard Platinum - Flex MD0000100140
Standard High Gold - Flex MD0000100141
HMO 2000 Low - Flex MD0000100142
Standard Silver MD0000100143
Standard High Bronze MD0000100145
HMO 3500 - Flex MD0000100155
HMO - OFF EXCHANGE with Dental SOB SBC
Standard Platinum - Flex MD0000100140
Standard High Gold - Flex MD0000100141
HMO 2000 Low - Flex MD0000100142
Standard Silver MD0000100143
Standard Low Silver HSA - Flex MD0000100144
Standard High Bronze MD0000100145
HMO 25 - Flex MD0000100147
HMO 500 - Flex MD0000100148
HMO 1000 - Flex MD0000100149
HMO 1500 - Flex MD0000100150
HMO 2000 - Flex MD0000100151
HMO 2000 with Coinsurance - Flex MD0000100152
HMO 2000 Value - Flex MD0000100153
HMO 3000 - Flex MD0000100154
HMO 3500 - Flex MD0000100155
HMO 1750 Core - Flex MD0000100156
HMO 3500 Core - Flex MD0000100157
HMO HSA 2000 - Flex MD0000100158
HMO HSA 3000 - Flex MD0000100159
HMO HSA 3400 - Flex MD0000100160
Focus HMO 25 MD0000100161
Focus HMO 1500 MD0000100162
Focus HMO HSA 3400 MD0000100163
HMO - ON EXCHANGE with Dental - AI/AN - Limited SOB SBC
Standard Platinum - Flex MD0000100140
Standard High Gold - Flex MD0000100141
HMO 2000 Low - Flex MD0000100142
Standard Silver MD0000100143
Standard High Bronze MD0000100145
HMO 3500 - Flex MD0000100155
HMO - ON EXCHANGE with Dental - AI/AN - $0 SOB SBC
HMO MD0000100139
HMO MD0000100139
HMO MD0000100139
HMO MD0000100139
HMO MD0000100139
HMO MD0000100139
PPO - OFF EXCHANGE with Dental SOB SBC
PPO 2000 - Flex MD0000100146
PPO 25 - Flex MD0000100164
PPO 500 - Flex MD0000100165
PPO 1000 - Flex MD0000100166
PPO 1500 - Flex MD0000100167
PPO 2000 with Coinsurance - Flex MD0000100168
PPO 3000 - Flex MD0000100169
PPO HSA 2000 - Flex MD0000100170
PPO HSA 3000 - Flex MD0000100171
PPO HSA 3400 - Flex MD0000100172
PPO HSA 5000 - Flex MD0000100173
PPO - OFF EXCHANGE without Dental SOB SBC
PPO 2000 - Flex MD0000100146
PPO 25 - Flex MD0000100164
PPO 500 - Flex MD0000100165
PPO 1000 - Flex MD0000100166
PPO 1500 - Flex MD0000100167
PPO 2000 with Coinsurance - Flex MD0000100168
PPO 3000 - Flex MD0000100169
PPO HSA 2000 - Flex MD0000100170
PPO HSA 3000 - Flex MD0000100171
PPO HSA 3400 - Flex MD0000100172
PPO HSA 5000 - Flex MD0000100173
HMO - OFF EXCHANGE without Dental SOB SBC
HMO 25 - Flex MD0000100147
HMO 500 - Flex MD0000100148
HMO 1000 - Flex MD0000100149
HMO 1500 - Flex MD0000100150
HMO 2000 - Flex MD0000100151
HMO 2000 with Coinsurance - Flex MD0000100152
HMO 2000 Value - Flex MD0000100153
HMO 3000 - Flex MD0000100154
HMO 3500 - Flex MD0000100155
HMO 1750 Core - Flex MD0000100156
HMO 3500 Core - Flex MD0000100157
HMO HSA 2000 - Flex MD0000100158
HMO HSA 3000 - Flex MD0000100159
HMO HSA 3400 - Flex MD0000100160
Focus HMO 25 MD0000100161
Focus HMO 1500 MD0000100162
Focus HMO HSA 3400 MD0000100163