Schedules of Benefits and SBCs: Massachusetts

Individual Market effective 1/1/23

HMO - OFF EXCHANGE with Dental	SOB	SBC
Standard Low Silver HSA - Flex MD0000200235	Show Standard Low Silver HSA - Flex SOB	Show Standard Low Silver HSA - Flex SBC

RX: RX0000200130 Vision: VS0000200085
HMO 25 - Flex MD0000200289	Show HMO 25 - Flex SOB	Show HMO 25 - Flex SBC

RX: RX0000200171 Vision: VS0000200094
HMO 500 - Flex MD0000200290	Show HMO 500 - Flex SOB	Show HMO 500 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
HMO 1000 - Flex MD0000200291	Show HMO 1000 - Flex SOB	Show HMO 1000 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
HMO 1500 - Flex MD0000200292	Show HMO 1500 - Flex SOB	Show HMO 1500 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
HMO 2000 - Flex MD0000200293	Show HMO 2000 - Flex SOB	Show HMO 2000 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
HMO 2500 - Flex MD0000200294	Show HMO 2500 - Flex SOB	Show HMO 2500 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
HMO 1500 with Coinsurance - Flex MD0000200295	Show HMO 1500 with Coinsurance - Flex SOB	Show HMO 1500 with Coinsurance - Flex SBC

RX: RX0000200173 Vision: VS0000200096
HMO 2000 with Coinsurance - Flex MD0000200296	Show HMO 2000 with Coinsurance - Flex SOB	Show HMO 2000 with Coinsurance - Flex SBC

RX: RX0000200173 Vision: VS0000200096
HMO 2000 Value - Flex MD0000200297	Show HMO 2000 Value - Flex SOB	Show HMO 2000 Value - Flex SBC

RX: RX0000200182 Vision: VS0000200097
HMO 3000 - Flex MD0000200298	Show HMO 3000 - Flex SOB	Show HMO 3000 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
HMO 4000 - Flex MD0000200299	Show HMO 4000 - Flex SOB	Show HMO 4000 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
HMO 5000 - Flex MD0000200300	Show HMO 5000 - Flex SOB	Show HMO 5000 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
HMO HSA 2000 - Flex MD0000200301	Show HMO HSA 2000 - Flex SOB	Show HMO HSA 2000 - Flex SBC

RX: RX0000200175 Vision: VS0000200098
HMO HSA 2500 - Flex MD0000200302	Show HMO HSA 2500 - Flex SOB	Show HMO HSA 2500 - Flex SBC

RX: RX0000200176 Vision: VS0000200098
HMO HSA 3000 - Flex MD0000200303	Show HMO HSA 3000 - Flex SOB	Show HMO HSA 3000 - Flex SBC

RX: RX0000200177 Vision: VS0000200098
HMO HSA 3400 - Flex MD0000200304	Show HMO HSA 3400 - Flex SOB	Show HMO HSA 3400 - Flex SBC

RX: RX0000200178 Vision: VS0000200098
HMO HSA 3600 - Flex MD0000200305	Show HMO HSA 3600 - Flex SOB	Show HMO HSA 3600 - Flex SBC

RX: RX0000200179 Vision: VS0000200098
Focus HMO 25 MD0000200306	Show Focus HMO 25 SOB	Show Focus HMO 25 SBC

RX: RX0000200171 Vision: VS0000200094
Focus HMO 1000 MD0000200307	Show Focus HMO 1000 SOB	Show Focus HMO 1000 SBC

RX: RX0000200172 Vision: VS0000200095
Focus HMO 1500 MD0000200308	Show Focus HMO 1500 SOB	Show Focus HMO 1500 SBC

RX: RX0000200172 Vision: VS0000200095
Focus HMO 2000 MD0000200309	Show Focus HMO 2000 SOB	Show Focus HMO 2000 SBC

RX: RX0000200172 Vision: VS0000200095
Focus HMO 2500 MD0000200310	Show Focus HMO 2500 SOB	Show Focus HMO 2500 SBC

RX: RX0000200172 Vision: VS0000200095
Focus HMO 3000 MD0000200311	Show Focus HMO 3000 SOB	Show Focus HMO 3000 SBC

RX: RX0000200174 Vision: VS0000200097
Focus HMO HSA 3400 MD0000200312	Show Focus HMO HSA 3400 SOB	Show Focus HMO HSA 3400 SBC

RX: RX0000200181 Vision: VS0000200099
Standard Platinum - Flex MD0000200230	Show Standard Platinum - Flex SOB	Show Standard Platinum - Flex SBC

RX: RX0000200125 Vision: VS0000200080
Standard High Gold - Flex MD0000200269	Show Standard High Gold - Flex SOB	Show Standard High Gold - Flex SBC

RX: RX0000200127 Vision: VS0000200082
HMO 2000 Low - Flex MD0000200233	Show HMO 2000 Low - Flex SOB	Show HMO 2000 Low - Flex SBC

RX: RX0000200128 Vision: VS0000200083
Standard Silver MD0000200234	Show Standard Silver SOB	Show Standard Silver SBC

RX: RX0000200129 Vision: VS0000200084
Standard High Bronze HSA - Flex MD0000200236	Show Standard High Bronze HSA - Flex SOB	Show Standard High Bronze HSA - Flex SBC

RX: RX0000200131 Vision: VS0000200086
HMO 3500 - Flex MD0000200238	Show HMO 3500 - Flex SOB	Show HMO 3500 - Flex SBC

RX: RX0000200133 Vision: VS0000200088

PPO - OFF EXCHANGE with Dental	SOB	SBC
PPO HSA 2000 - Flex MD0000200239	Show PPO HSA 2000 - Flex SOB	Show PPO HSA 2000 - Flex SBC

RX: RX0000200130 Vision: VS0000200085
PPO 25 - Flex MD0000200313	Show PPO 25 - Flex SOB	Show PPO 25 - Flex SBC

RX: RX0000200171 Vision: VS0000200094
PPO 500 - Flex MD0000200314	Show PPO 500 - Flex SOB	Show PPO 500 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
PPO 1000 - Flex MD0000200315	Show PPO 1000 - Flex SOB	Show PPO 1000 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
PPO 1500 - Flex MD0000200316	Show PPO 1500 - Flex SOB	Show PPO 1500 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
PPO 2000 - Flex MD0000200317	Show PPO 2000 - Flex SOB	Show PPO 2000 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
PPO 2000 Value - Flex MD0000200318	Show PPO 2000 Value - Flex SOB	Show PPO 2000 Value - Flex SBC

RX: RX0000200174 Vision: VS0000200097
PPO 3000 - Flex MD0000200319	Show PPO 3000 - Flex SOB	Show PPO 3000 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
PPO 4000 - Flex MD0000200320	Show PPO 4000 - Flex SOB	Show PPO 4000 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
PPO HSA 3000 - Flex MD0000200321	Show PPO HSA 3000 - Flex SOB	Show PPO HSA 3000 - Flex SBC

RX: RX0000200177 Vision: VS0000200098
PPO HSA 3400 - Flex MD0000200322	Show PPO HSA 3400 - Flex SOB	Show PPO HSA 3400 - Flex SBC

RX: RX0000200178 Vision: VS0000200098
PPO HSA 5000 - Flex MD0000200323	Show PPO HSA 5000 - Flex SOB	Show PPO HSA 5000 - Flex SBC

RX: RX0000200180 Vision: VS0000200098

HMO - OFF EXCHANGE without Dental	SOB	SBC
HMO 25 - Flex MD0000200289	Show HMO 25 - Flex SOB	Show HMO 25 - Flex SBC

RX: RX0000200171 Vision: VS0000200094
HMO 500 - Flex MD0000200290	Show HMO 500 - Flex SOB	Show HMO 500 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
HMO 1000 - Flex MD0000200291	Show HMO 1000 - Flex SOB	Show HMO 1000 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
HMO 1500 - Flex MD0000200292	Show HMO 1500 - Flex SOB	Show HMO 1500 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
HMO 2000 - Flex MD0000200293	Show HMO 2000 - Flex SOB	Show HMO 2000 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
HMO 2500 - Flex MD0000200294	Show HMO 2500 - Flex SOB	Show HMO 2500 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
HMO 1500 with Coinsurance - Flex MD0000200295	Show HMO 1500 with Coinsurance - Flex SOB	Show HMO 1500 with Coinsurance - Flex SBC

RX: RX0000200173 Vision: VS0000200096
HMO 2000 with Coinsurance - Flex MD0000200296	Show HMO 2000 with Coinsurance - Flex SOB	Show HMO 2000 with Coinsurance - Flex SBC

RX: RX0000200173 Vision: VS0000200096
HMO 2000 Value - Flex MD0000200297	Show HMO 2000 Value - Flex SOB	Show HMO 2000 Value - Flex SBC

RX: RX0000200182 Vision: VS0000200097
HMO 3000 - Flex MD0000200298	Show HMO 3000 - Flex SOB	Show HMO 3000 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
HMO 4000 - Flex MD0000200299	Show HMO 4000 - Flex SOB	Show HMO 4000 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
HMO 5000 - Flex MD0000200300	Show HMO 5000 - Flex SOB	Show HMO 5000 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
HMO HSA 2000 - Flex MD0000200301	Show HMO HSA 2000 - Flex SOB	Show HMO HSA 2000 - Flex SBC

RX: RX0000200175 Vision: VS0000200098
HMO HSA 2500 - Flex MD0000200302	Show HMO HSA 2500 - Flex SOB	Show HMO HSA 2500 - Flex SBC

RX: RX0000200176 Vision: VS0000200098
HMO HSA 3000 - Flex MD0000200303	Show HMO HSA 3000 - Flex SOB	Show HMO HSA 3000 - Flex SBC

RX: RX0000200177 Vision: VS0000200098
HMO HSA 3400 - Flex MD0000200304	Show HMO HSA 3400 - Flex SOB	Show HMO HSA 3400 - Flex SBC

RX: RX0000200178 Vision: VS0000200098
HMO HSA 3600 - Flex MD0000200305	Show HMO HSA 3600 - Flex SOB	Show HMO HSA 3600 - Flex SBC

RX: RX0000200179 Vision: VS0000200098
Focus HMO 25 MD0000200306	Show Focus HMO 25 SOB	Show Focus HMO 25 SBC

RX: RX0000200171 Vision: VS0000200094
Focus HMO 1000 MD0000200307	Show Focus HMO 1000 SOB	Show Focus HMO 1000 SBC

RX: RX0000200172 Vision: VS0000200095
Focus HMO 1500 MD0000200308	Show Focus HMO 1500 SOB	Show Focus HMO 1500 SBC

RX: RX0000200172 Vision: VS0000200095
Focus HMO 2000 MD0000200309	Show Focus HMO 2000 SOB	Show Focus HMO 2000 SBC

RX: RX0000200172 Vision: VS0000200095
Focus HMO 2500 MD0000200310	Show Focus HMO 2500 SOB	Show Focus HMO 2500 SBC

RX: RX0000200172 Vision: VS0000200095
Focus HMO 3000 MD0000200311	Show Focus HMO 3000 SOB	Show Focus HMO 3000 SBC

RX: RX0000200174 Vision: VS0000200097
Focus HMO HSA 3400 MD0000200312	Show Focus HMO HSA 3400 SOB	Show Focus HMO HSA 3400 SBC

RX: RX0000200181 Vision: VS0000200099

PPO - OFF EXCHANGE without Dental	SOB	SBC
PPO 25 - Flex MD0000200313	Show PPO 25 - Flex SOB	Show PPO 25 - Flex SBC

RX: RX0000200171 Vision: VS0000200094
PPO 500 - Flex MD0000200314	Show PPO 500 - Flex SOB	Show PPO 500 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
PPO 1000 - Flex MD0000200315	Show PPO 1000 - Flex SOB	Show PPO 1000 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
PPO 1500 - Flex MD0000200316	Show PPO 1500 - Flex SOB	Show PPO 1500 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
PPO 2000 - Flex MD0000200317	Show PPO 2000 - Flex SOB	Show PPO 2000 - Flex SBC

RX: RX0000200172 Vision: VS0000200095
PPO 2000 Value - Flex MD0000200318	Show PPO 2000 Value - Flex SOB	Show PPO 2000 Value - Flex SBC

RX: RX0000200174 Vision: VS0000200097
PPO 3000 - Flex MD0000200319	Show PPO 3000 - Flex SOB	Show PPO 3000 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
PPO 4000 - Flex MD0000200320	Show PPO 4000 - Flex SOB	Show PPO 4000 - Flex SBC

RX: RX0000200174 Vision: VS0000200097
PPO HSA 3000 - Flex MD0000200321	Show PPO HSA 3000 - Flex SOB	Show PPO HSA 3000 - Flex SBC

RX: RX0000200177 Vision: VS0000200098
PPO HSA 3400 - Flex MD0000200322	Show PPO HSA 3400 - Flex SOB	Show PPO HSA 3400 - Flex SBC

RX: RX0000200178 Vision: VS0000200098
PPO HSA 5000 - Flex MD0000200323	Show PPO HSA 5000 - Flex SOB	Show PPO HSA 5000 - Flex SBC

RX: RX0000200180 Vision: VS0000200098

HMO - ON EXCHANGE with Dental	SOB	SBC
Standard Platinum - Flex MD0000200230	Show Standard Platinum - Flex SOB	Show Standard Platinum - Flex SBC

RX: RX0000200125 Vision: VS0000200080
Standard High Gold - Flex MD0000200269	Show Standard High Gold - Flex SOB	Show Standard High Gold - Flex SBC

RX: RX0000200127 Vision: VS0000200082
HMO 2000 Low - Flex MD0000200233	Show HMO 2000 Low - Flex SOB	Show HMO 2000 Low - Flex SBC

RX: RX0000200128 Vision: VS0000200083
Standard Silver MD0000200234	Show Standard Silver SOB	Show Standard Silver SBC

RX: RX0000200129 Vision: VS0000200084
Standard High Bronze HSA - Flex MD0000200236	Show Standard High Bronze HSA - Flex SOB	Show Standard High Bronze HSA - Flex SBC

RX: RX0000200131 Vision: VS0000200086
HMO 3500 - Flex MD0000200238	Show HMO 3500 - Flex SOB	Show HMO 3500 - Flex SBC

RX: RX0000200133 Vision: VS0000200088

HMO - ON EXCHANGE with Dental - AI/AN - Limited	SOB	SBC
Standard Platinum - Flex MD0000200230	Show Standard Platinum - Flex SOB	Show Standard Platinum - Flex SBC

RX: RX0000200125 Vision: VS0000200080
Standard High Gold - Flex MD0000200269	Show Standard High Gold - Flex SOB	Show Standard High Gold - Flex SBC

RX: RX0000200127 Vision: VS0000200082
HMO 2000 Low - Flex MD0000200233	Show HMO 2000 Low - Flex SOB	Show HMO 2000 Low - Flex SBC

RX: RX0000200128 Vision: VS0000200083
Standard Silver MD0000200234	Show Standard Silver SOB	Show Standard Silver SBC

RX: RX0000200129 Vision: VS0000200084
Standard High Bronze HSA - Flex MD0000200236	Show Standard High Bronze HSA - Flex SOB	Show Standard High Bronze HSA - Flex SBC

RX: RX0000200131 Vision: VS0000200086
HMO 3500 - Flex MD0000200238	Show HMO 3500 - Flex SOB	Show HMO 3500 - Flex SBC

RX: RX0000200133 Vision: VS0000200088

HMO - ON EXCHANGE with Dental - AI/AN - $0	SOB	SBC
HMO MD0000200231	Show HMO SOB	Show HMO SBC

RX: RX0000200126 Vision: VS0000200081
HMO MD0000200231	Show HMO SOB	Show HMO SBC

RX: RX0000200126 Vision: VS0000200081
HMO MD0000200231	Show HMO SOB	Show HMO SBC

RX: RX0000200126 Vision: VS0000200081
HMO MD0000200231	Show HMO SOB	Show HMO SBC

RX: RX0000200126 Vision: VS0000200081
HMO MD0000200231	Show HMO SOB	Show HMO SBC

RX: RX0000200126 Vision: VS0000200081
HMO MD0000200231	Show HMO SOB	Show HMO SBC

RX: RX0000200126 Vision: VS0000200081

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Individual Market effective 1/1/23