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Home > Members > MA 2018 Individual Market

Schedules of Benefits and SBCs: Massachusetts

Individual Market effective 1/1/18

HMO - ON EXCHANGE with Dental SOB SBC
Standard Platinum MD0000004598
Standard Gold MD0000004599
Standard Silver MD0000004600
Standard Bronze MD0000004601

HMO - ON EXCHANGE with Dental - AI/AN - $0 SOB SBC
HMO MD0000004605
HMO MD0000004605
HMO MD0000004605
HMO MD0000004605

HMO - ON EXCHANGE with Dental - AI/AN - LIMITED SOB SBC
Standard Platinum MD0000004598
Standard Gold MD0000004599
Standard Silver MD0000004600
Standard Bronze MD0000004601

HMO - OFF EXCHANGE with Dental SOB SBC
Standard Platinum MD0000004598
Standard Gold MD0000004599
Standard Silver MD0000004600
Standard Bronze MD0000004601
Affordable HMO 25 - FLEX MD0000004607
Best Buy HMO 1000 - FLEX MD0000004608
Best Buy HMO 1000 with Coinsurance - FLEX MD0000004609
Best Buy HMO 2000 - FLEX MD0000004610
Best Buy HMO 2000 with Coinsurance - FLEX MD0000004611
Best Buy HSA HMO 2000 - FLEX MD0000004612
Best Buy HSA HMO 2000 with Coinsurance - FLEX MD0000004613
Best Buy HSA HMO 3000 - FLEX MD0000004614
Best Buy HSA HMO 3100 - FLEX MD0000004615
Core Coverage HMO 1750 - FLEX MD0000004616
Core Coverage HMO 3000 - FLEX MD0000004617
Best Buy HMO 500 - FLEX MD0000004618
Best Buy HMO 2000 with Copayment - FLEX MD0000004619
Best Buy HMO 3000 - FLEX MD0000004620
Best Buy HSA HMO 2000 with Cost Share - FLEX MD0000004621
Best Buy HSA HMO 3000 with Cost Share - FLEX MD0000004622
Focus Network MA- Affordable HMO 25 MD0000004623
Focus Network MA - Best Buy HSA HMO 3100 MD0000004624

HMO - OFF EXCHANGE without Dental SOB SBC
Affordable HMO 25 - FLEX MD0000004607
Best Buy HMO 1000 - FLEX MD0000004608
Best Buy HMO 1000 with Coinsurance - FLEX MD0000004609
Best Buy HMO 2000 - FLEX MD0000004610
Best Buy HMO 2000 with Coinsurance - FLEX MD0000004611
Best Buy HSA HMO 2000 - FLEX MD0000004612
Best Buy HSA HMO 2000 with Coinsurance - FLEX MD0000004613
Best Buy HSA HMO 3000 - FLEX MD0000004614
Best Buy HSA HMO 3100 - FLEX MD0000004615
Best Buy HMO 500 - FLEX MD0000004618
Best Buy HMO 2000 with Copayment - FLEX MD0000004619
Best Buy HSA HMO 2000 with Cost Share - FLEX MD0000004621
Best Buy HSA HMO 3000 with Cost Share - FLEX MD0000004622
Focus Network MA- Affordable HMO 25 MD0000004623
Focus Network MA - Best Buy HSA HMO 3100 MD0000004624

PPO - OFF EXCHANGE with Dental SOB SBC
Affordable PPO 25 - FLEX MD0000004625
Best Buy PPO 1000 - FLEX MD0000004626
Best Buy PPO 500 - FLEX MD0000004627
Best Buy PPO 1000 with Coinsurance - FLEX MD0000004628
Best Buy PPO 2000 - FLEX MD0000004629
Best Buy PPO 2000 with Coinsurance - FLEX MD0000004630
Best Buy PPO 3000 - FLEX MD0000004631
Best Buy PPO 2000 with Copayment - FLEX MD0000004632
Best Buy HSA PPO 2000 - FLEX MD0000004633
Best Buy HSA PPO 2000 with Cost Share - FLEX MD0000004634
Best Buy HSA PPO 2000 with Coinsurance - FLEX MD0000004635
Best Buy HSA PPO 3000 - FLEX MD0000004636
Best Buy HSA PPO 3000 with Cost Share - FLEX MD0000004637
Best Buy HSA PPO 3100 - FLEX MD0000004638
Best Buy HSA PPO 4500 - FLEX MD0000004639

PPO - OFF EXCHANGE without Dental SOB SBC
Affordable PPO 25 - FLEX MD0000004625
Best Buy PPO 1000 - FLEX MD0000004626
Best Buy PPO 500 - FLEX MD0000004627
Best Buy PPO 1000 with Coinsurance - FLEX MD0000004628
Best Buy PPO 2000 - FLEX MD0000004629
Best Buy PPO 2000 with Coinsurance - FLEX MD0000004630
Best Buy PPO 2000 with Copayment - FLEX MD0000004632
Best Buy HSA PPO 2000 - FLEX MD0000004633
Best Buy HSA PPO 2000 with Cost Share - FLEX MD0000004634
Best Buy HSA PPO 2000 with Coinsurance - FLEX MD0000004635
Best Buy HSA PPO 3000 - FLEX MD0000004636
Best Buy HSA PPO 3000 with Cost Share - FLEX MD0000004637
Best Buy HSA PPO 3100 - FLEX MD0000004638
Best Buy HSA PPO 4500 - FLEX MD0000004639