Schedules of Benefits and SBCs: Massachusetts

Individual Market effective 1/1/22

HMO - ON EXCHANGE with Dental SOB SBC
Standard Platinum - Flex MD0000100363
Standard High Gold - Flex MD0000100365
HMO 2000 Low - Flex MD0000100366
Standard Silver MD0000100367
Standard High Bronze MD0000100369
HMO 3500 - Flex MD0000100371
HMO - OFF EXCHANGE with Dental SOB SBC
Standard Platinum - Flex MD0000100363
Standard High Gold - Flex MD0000100365
HMO 2000 Low - Flex MD0000100366
Standard Silver MD0000100367
Standard High Bronze MD0000100369
HMO 3500 - Flex MD0000100371
Standard Low Silver HSA - Flex MD0000100368
HMO 25 - Flex MD0000100514
HMO 500 - Flex MD0000100515
HMO 1000 - Flex MD0000100516
HMO 1500 - Flex MD0000100517
HMO 2000 - Flex MD0000100518
HMO 2000 with Coinsurance - Flex MD0000100519
HMO 2000 Value - Flex MD0000100520
HMO 3000 - Flex MD0000100521
HMO HSA 2000 - Flex MD0000100524
HMO HSA 3000 - Flex MD0000100525
HMO HSA 3400 - Flex MD0000100526
Focus HMO 25 MD0000100527
Focus HMO 1500 MD0000100528
Focus HMO HSA 3400 MD0000100529
HMO 1500 with Coinsurance - Flex MD0000100542
HMO 2500 - Flex MD0000100543
HMO 4000 - Flex MD0000100544
HMO 5000 - Flex MD0000100545
Focus HMO 1000 MD0000100564
Focus HMO 2000 MD0000100565
Focus HMO 2500 MD0000100566
Focus HMO 3000 MD0000100567
HMO HSA 2500 - Flex MD0000100568
HMO HSA 3600 - Flex MD0000100577
HMO - ON EXCHANGE with Dental - AI/AN - Limited SOB SBC
Standard Platinum - Flex MD0000100363
Standard High Gold - Flex MD0000100365
HMO 2000 Low - Flex MD0000100366
Standard Silver MD0000100367
Standard High Bronze MD0000100369
HMO 3500 - Flex MD0000100371
HMO - ON EXCHANGE with Dental - AI/AN - $0 SOB SBC
HMO MD0000100364
HMO MD0000100364
HMO MD0000100364
HMO MD0000100364
HMO MD0000100364
HMO MD0000100364
PPO - OFF EXCHANGE with Dental SOB SBC
PPO 2000 - Flex MD0000100370
PPO 25 - Flex MD0000100530
PPO 500 - Flex MD0000100531
PPO 1000 - Flex MD0000100532
PPO 3000 - Flex MD0000100535
PPO HSA 2000 - Flex MD0000100536
PPO HSA 3000 - Flex MD0000100537
PPO HSA 3400 - Flex MD0000100538
PPO HSA 5000 - Flex MD0000100539
PPO 1500 - Flex MD0000100558
PPO 2000 Low - Flex MD0000100559
PPO 4000 - Flex MD0000100562
PPO - OFF EXCHANGE without Dental SOB SBC
PPO 2000 - Flex MD0000100370
PPO 25 - Flex MD0000100530
PPO 500 - Flex MD0000100531
PPO 1000 - Flex MD0000100532
PPO 3000 - Flex MD0000100535
PPO HSA 2000 - Flex MD0000100536
PPO HSA 3000 - Flex MD0000100537
PPO HSA 3400 - Flex MD0000100538
PPO HSA 5000 - Flex MD0000100539
PPO 1500 - Flex MD0000100558
PPO 2000 Low - Flex MD0000100559
PPO 4000 - Flex MD0000100562
HMO - OFF EXCHANGE without Dental SOB SBC
HMO 3500 - Flex MD0000100371
HMO 25 - Flex MD0000100514
HMO 500 - Flex MD0000100515
HMO 1000 - Flex MD0000100516
HMO 1500 - Flex MD0000100517
HMO 2000 - Flex MD0000100518
HMO 2000 with Coinsurance - Flex MD0000100519
HMO 2000 Value - Flex MD0000100520
HMO 3000 - Flex MD0000100521
HMO HSA 2000 - Flex MD0000100524
HMO HSA 3000 - Flex MD0000100525
HMO HSA 3400 - Flex MD0000100526
Focus HMO 25 MD0000100527
Focus HMO 1500 MD0000100528
Focus HMO HSA 3400 MD0000100529
HMO 1500 with Coinsurance - Flex MD0000100542
HMO 2500 - Flex MD0000100543
HMO 4000 - Flex MD0000100544
HMO 5000 - Flex MD0000100545
Focus HMO 1000 MD0000100564
Focus HMO 2000 MD0000100565
Focus HMO 2500 MD0000100566
Focus HMO 3000 MD0000100567
HMO HSA 2500 - Flex MD0000100568
HMO HSA 3600 - Flex MD0000100577