Schedules of Benefits and SBCs: New Hampshire

Individual Market effective 1/1/23

HMO - OFF EXCHANGE with Dental	SOB	SBC
NH Local Choice HMO Gold 1500 MD0000200125	Show NH Local Choice HMO Gold 1500 SOB	Show NH Local Choice HMO Gold 1500 SBC

RX: RX0000200056 Vision: VS0000200032
NH Local Choice HMO Silver 2500 MD0000200126	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000200057 Vision: VS0000200035
NH Local Choice HMO Silver 3500 MD0000200128	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000200058 Vision: VS0000200032
NH Local Choice HMO Silver 4000 MD0000200131	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000200059 Vision: VS0000200032
NH Local Choice HMO Silver 5000 MD0000200135	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000200060 Vision: VS0000200032
NH Local Choice HMO Bronze 6500 MD0000200138	Show NH Local Choice HMO Bronze 6500 SOB	Show NH Local Choice HMO Bronze 6500 SBC

RX: RX0000200061 Vision: VS0000200032
NH Local Choice HMO Bronze 7200 MD0000200159	Show NH Local Choice HMO Bronze 7200 SOB	Show NH Local Choice HMO Bronze 7200 SBC

RX: RX0000200062 Vision: VS0000200032
NH Local Choice HMO Bronze 8000 MD0000200160	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000200063 Vision: VS0000200035
NH Local Choice HMO HSA Silver 3500 MD0000200163	Show NH Local Choice HMO HSA Silver 3500 SOB	Show NH Local Choice HMO HSA Silver 3500 SBC

RX: RX0000200080 Vision: VS0000200033
NH Local Choice HMO HSA Bronze 6000 MD0000200164	Show NH Local Choice HMO HSA Bronze 6000 SOB	Show NH Local Choice HMO HSA Bronze 6000 SBC

RX: RX0000200081 Vision: VS0000200033

HMO - OFF EXCHANGE without Dental	SOB	SBC
NH Local Choice HMO Gold 1500 MD0000200125	Show NH Local Choice HMO Gold 1500 SOB	Show NH Local Choice HMO Gold 1500 SBC

RX: RX0000200056 Vision: VS0000200032
NH Local Choice HMO Silver 2500 MD0000200127	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000200057 Vision: VS0000200035
NH Local Choice HMO Silver 3500 MD0000200129	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000200058 Vision: VS0000200032
NH Local Choice HMO Silver 4000 MD0000200130	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000200059 Vision: VS0000200032
NH Local Choice HMO Silver 5000 MD0000200132	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000200060 Vision: VS0000200032
NH Local Choice HMO Bronze 6500 MD0000200138	Show NH Local Choice HMO Bronze 6500 SOB	Show NH Local Choice HMO Bronze 6500 SBC

RX: RX0000200061 Vision: VS0000200032
NH Local Choice HMO Bronze 7200 MD0000200159	Show NH Local Choice HMO Bronze 7200 SOB	Show NH Local Choice HMO Bronze 7200 SBC

RX: RX0000200062 Vision: VS0000200032
NH Local Choice HMO Bronze 8000 MD0000200160	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000200063 Vision: VS0000200035
NH Local Choice HMO HSA Silver 3500 MD0000200162	Show NH Local Choice HMO HSA Silver 3500 SOB	Show NH Local Choice HMO HSA Silver 3500 SBC

RX: RX0000200080 Vision: VS0000200033
NH Local Choice HMO HSA Bronze 6000 MD0000200164	Show NH Local Choice HMO HSA Bronze 6000 SOB	Show NH Local Choice HMO HSA Bronze 6000 SBC

RX: RX0000200081 Vision: VS0000200033
NH Local HMO Gold 2000 Standard MD0000200244	Show NH Local HMO Gold 2000 Standard SOB	Show NH Local HMO Gold 2000 Standard SBC

RX: RX0000200138 Vision: VS0000200032
NH Local HMO Silver 5800 Standard MD0000200245	Show NH Local HMO Silver 5800 Standard SOB	Show NH Local HMO Silver 5800 Standard SBC

RX: RX0000200140 Vision: VS0000200059
NH Local HMO Bronze 9100 Standard MD0000200249	Show NH Local HMO Bronze 9100 Standard SOB	Show NH Local HMO Bronze 9100 Standard SBC

RX: RX0000200144 Vision: VS0000200035
NH Local HMO Bronze 7500 Standard MD0000200250	Show NH Local HMO Bronze 7500 Standard SOB	Show NH Local HMO Bronze 7500 Standard SBC

RX: RX0000200145 Vision: VS0000200063

HMO - ON EXCHANGE without Dental	SOB	SBC
NH Local Choice HMO Gold 1500 MD0000200125	Show NH Local Choice HMO Gold 1500 SOB	Show NH Local Choice HMO Gold 1500 SBC

RX: RX0000200056 Vision: VS0000200032
NH Local Choice HMO Silver 2500 MD0000200127	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000200057 Vision: VS0000200035
NH Local Choice HMO Silver 3500 MD0000200129	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000200058 Vision: VS0000200032
NH Local Choice HMO Silver 4000 MD0000200130	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000200059 Vision: VS0000200032
NH Local Choice HMO Silver 5000 MD0000200132	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000200060 Vision: VS0000200032
NH Local Choice HMO Bronze 6500 MD0000200138	Show NH Local Choice HMO Bronze 6500 SOB	Show NH Local Choice HMO Bronze 6500 SBC

RX: RX0000200061 Vision: VS0000200032
NH Local Choice HMO Bronze 7200 MD0000200159	Show NH Local Choice HMO Bronze 7200 SOB	Show NH Local Choice HMO Bronze 7200 SBC

RX: RX0000200062 Vision: VS0000200032
NH Local Choice HMO Bronze 8000 MD0000200160	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000200063 Vision: VS0000200035
NH Local Choice HMO HSA Silver 3500 MD0000200162	Show NH Local Choice HMO HSA Silver 3500 SOB	Show NH Local Choice HMO HSA Silver 3500 SBC

RX: RX0000200080 Vision: VS0000200033
NH Local Choice HMO HSA Bronze 6000 MD0000200164	Show NH Local Choice HMO HSA Bronze 6000 SOB	Show NH Local Choice HMO HSA Bronze 6000 SBC

RX: RX0000200081 Vision: VS0000200033
NH Local HMO Gold 2000 Standard MD0000200244	Show NH Local HMO Gold 2000 Standard SOB	Show NH Local HMO Gold 2000 Standard SBC

RX: RX0000200138 Vision: VS0000200032
NH Local HMO Silver 5800 Standard MD0000200245	Show NH Local HMO Silver 5800 Standard SOB	Show NH Local HMO Silver 5800 Standard SBC

RX: RX0000200140 Vision: VS0000200059
NH Local HMO Bronze 9100 Standard MD0000200249	Show NH Local HMO Bronze 9100 Standard SOB	Show NH Local HMO Bronze 9100 Standard SBC

RX: RX0000200144 Vision: VS0000200035
NH Local HMO Bronze 7500 Standard MD0000200250	Show NH Local HMO Bronze 7500 Standard SOB	Show NH Local HMO Bronze 7500 Standard SBC

RX: RX0000200145 Vision: VS0000200063

HMO - ON EXCHANGE without Dental - AI/AN - Limited	SOB	SBC
NH Local Choice HMO Gold 1500 MD0000200125	Show NH Local Choice HMO Gold 1500 SOB	Show NH Local Choice HMO Gold 1500 SBC

RX: RX0000200056 Vision: VS0000200032
NH Local Choice HMO Silver 2500 MD0000200127	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000200057 Vision: VS0000200035
NH Local Choice HMO Silver 3500 MD0000200129	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000200058 Vision: VS0000200032
NH Local Choice HMO Silver 4000 MD0000200130	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000200059 Vision: VS0000200032
NH Local Choice HMO Silver 5000 MD0000200132	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000200060 Vision: VS0000200032
NH Local Choice HMO Bronze 6500 MD0000200138	Show NH Local Choice HMO Bronze 6500 SOB	Show NH Local Choice HMO Bronze 6500 SBC

RX: RX0000200061 Vision: VS0000200032
NH Local Choice HMO Bronze 7200 MD0000200159	Show NH Local Choice HMO Bronze 7200 SOB	Show NH Local Choice HMO Bronze 7200 SBC

RX: RX0000200062 Vision: VS0000200032
NH Local Choice HMO Bronze 8000 MD0000200160	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000200063 Vision: VS0000200035
NH Local Choice HMO HSA Silver 3500 MD0000200162	Show NH Local Choice HMO HSA Silver 3500 SOB	Show NH Local Choice HMO HSA Silver 3500 SBC

RX: RX0000200080 Vision: VS0000200033
NH Local Choice HMO HSA Bronze 6000 MD0000200164	Show NH Local Choice HMO HSA Bronze 6000 SOB	Show NH Local Choice HMO HSA Bronze 6000 SBC

RX: RX0000200081 Vision: VS0000200033
NH Local HMO Gold 2000 Standard MD0000200244	Show NH Local HMO Gold 2000 Standard SOB	Show NH Local HMO Gold 2000 Standard SBC

RX: RX0000200138 Vision: VS0000200032
NH Local HMO Silver 5800 Standard MD0000200245	Show NH Local HMO Silver 5800 Standard SOB	Show NH Local HMO Silver 5800 Standard SBC

RX: RX0000200140 Vision: VS0000200059
NH Local HMO Bronze 9100 Standard MD0000200249	Show NH Local HMO Bronze 9100 Standard SOB	Show NH Local HMO Bronze 9100 Standard SBC

RX: RX0000200144 Vision: VS0000200035
NH Local HMO Bronze 7500 Standard MD0000200250	Show NH Local HMO Bronze 7500 Standard SOB	Show NH Local HMO Bronze 7500 Standard SBC

RX: RX0000200145 Vision: VS0000200063

HMO - ON EXCHANGE without Dental - AI/AN - $0	SOB	SBC
NH Local Choice HMO MD0000200137	Show NH Local Choice HMO SOB	Show NH Local Choice HMO SBC

RX: RX0000200079 Vision: VS0000200044
NH Local Choice HMO MD0000200137	Show NH Local Choice HMO SOB	Show NH Local Choice HMO SBC

RX: RX0000200079 Vision: VS0000200044
NH Local Choice HMO MD0000200137	Show NH Local Choice HMO SOB	Show NH Local Choice HMO SBC

RX: RX0000200079 Vision: VS0000200044
NH Local Choice HMO MD0000200137	Show NH Local Choice HMO SOB	Show NH Local Choice HMO SBC

RX: RX0000200079 Vision: VS0000200044
NH Local Choice HMO MD0000200137	Show NH Local Choice HMO SOB	Show NH Local Choice HMO SBC

RX: RX0000200079 Vision: VS0000200044
NH Local Choice HMO MD0000200137	Show NH Local Choice HMO SOB	Show NH Local Choice HMO SBC

RX: RX0000200079 Vision: VS0000200044
NH Local Choice HMO MD0000200137	Show NH Local Choice HMO SOB	Show NH Local Choice HMO SBC

RX: RX0000200079 Vision: VS0000200044
NH Local Choice HMO MD0000200137	Show NH Local Choice HMO SOB	Show NH Local Choice HMO SBC

RX: RX0000200079 Vision: VS0000200044
NH Local Choice HMO MD0000200137	Show NH Local Choice HMO SOB	Show NH Local Choice HMO SBC

RX: RX0000200079 Vision: VS0000200044
NH Local Choice HMO MD0000200137	Show NH Local Choice HMO SOB	Show NH Local Choice HMO SBC

RX: RX0000200079 Vision: VS0000200044
NH Local HMO MD0000200268	Show NH Local HMO SOB	Show NH Local HMO SBC

RX: RX0000200139 Vision: VS0000200044
NH Local HMO MD0000200268	Show NH Local HMO SOB	Show NH Local HMO SBC

RX: RX0000200139 Vision: VS0000200044
NH Local HMO MD0000200268	Show NH Local HMO SOB	Show NH Local HMO SBC

RX: RX0000200139 Vision: VS0000200044
NH Local HMO MD0000200268	Show NH Local HMO SOB	Show NH Local HMO SBC

RX: RX0000200139 Vision: VS0000200044

HMO - ON EXCHANGE without Dental - CSR - 73%	SOB	SBC
NH Local Choice HMO Silver 2500 MD0000200133	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000200064 Vision: VS0000200034
NH Local Choice HMO Silver 3500 MD0000200141	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000200067 Vision: VS0000200038
NH Local Choice HMO Silver 4000 MD0000200144	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000200070 Vision: VS0000200040
NH Local Choice HMO Silver 5000 MD0000200147	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000200073 Vision: VS0000200034
NH Local Choice HMO Silver 3500 MD0000200151	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000200076 Vision: VS0000200034
NH Local HMO Silver 5800 Standard MD0000200246	Show NH Local HMO Silver 5800 Standard SOB	Show NH Local HMO Silver 5800 Standard SBC

RX: RX0000200141 Vision: VS0000200060

HMO - ON EXCHANGE without Dental - CSR - 87%	SOB	SBC
NH Local Choice HMO Silver 2500 MD0000200134	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000200065 Vision: VS0000200036
NH Local Choice HMO Silver 3500 MD0000200142	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000200068 Vision: VS0000200039
NH Local Choice HMO Silver 4000 MD0000200145	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000200071 Vision: VS0000200041
NH Local Choice HMO Silver 5000 MD0000200148	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000200074 Vision: VS0000200039
NH Local Choice HMO Silver 3500 MD0000200156	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000200077 Vision: VS0000200042
NH Local HMO Silver 5800 Standard MD0000200247	Show NH Local HMO Silver 5800 Standard SOB	Show NH Local HMO Silver 5800 Standard SBC

RX: RX0000200142 Vision: VS0000200061

HMO - ON EXCHANGE without Dental - CSR - 94%	SOB	SBC
NH Local Choice HMO Silver 2500 MD0000200140	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000200066 Vision: VS0000200037
NH Local Choice HMO Silver 3500 MD0000200143	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000200069 Vision: VS0000200037
NH Local Choice HMO Silver 4000 MD0000200146	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000200072 Vision: VS0000200037
NH Local Choice HMO Silver 5000 MD0000200149	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000200075 Vision: VS0000200037
NH Local Choice HMO Silver 3500 MD0000200158	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000200078 Vision: VS0000200043
NH Local HMO Silver 5800 Standard MD0000200248	Show NH Local HMO Silver 5800 Standard SOB	Show NH Local HMO Silver 5800 Standard SBC

RX: RX0000200143 Vision: VS0000200062

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Individual Market effective 1/1/23