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Home > Members > MA 2020 Individual Market

Schedules of Benefits and SBCs: Massachusetts

Individual Market effective 1/1/20

HMO - ON EXCHANGE with Dental SOB SBC
Standard Platinum - Flex MD0000005157
Standard High Gold - Flex MD0000005158
Standard Low Gold - Flex MD0000005159
Standard Silver MD0000005160
Standard High Bronze MD0000005162

HMO - ON EXCHANGE with Dental - AI/AN - $0 SOB SBC
HMO MD0000005170
HMO MD0000005170
HMO MD0000005170
HMO MD0000005170
HMO MD0000005170

HMO - ON EXCHANGE with Dental - AI/AN - LIMITED SOB SBC
Standard Platinum - Flex MD0000005157
Standard High Gold - Flex MD0000005158
Standard Low Gold - Flex MD0000005159
Standard Silver MD0000005160
Standard High Bronze MD0000005162

HMO - OFF EXCHANGE with Dental SOB SBC
Standard Platinum - Flex MD0000005157
Standard High Gold - Flex MD0000005158
Standard Low Gold - Flex MD0000005159
Standard Silver MD0000005160
Standard Low Silver HSA - Flex MD0000005161
Standard High Bronze MD0000005162
HMO 25 - Flex MD0000005171
HMO 500 - Flex MD0000005172
HMO 1000 - Flex MD0000005173
HMO 1500 - Flex MD0000005174
HMO 2000 - Flex MD0000005175
HMO 2000 with Coinsurance - Flex MD0000005176
HMO 2500 - Flex MD0000005177
HMO 3500 - Flex MD0000005178
HMO 1750 Core - Flex MD0000005179
HMO 3500 Core - Flex MD0000005180
HMO HSA 2000 - Flex MD0000005181
HMO HSA 3000 - Flex MD0000005182
HMO HSA 3400 - Flex MD0000005183
Focus HMO 25 MD0000005184
Focus HMO 1500 MD0000005185
Focus HMO HSA 3400 MD0000005186

HMO - OFF EXCHANGE without Dental SOB SBC
HMO 25 - Flex MD0000005171
HMO 500 - Flex MD0000005172
HMO 1000 - Flex MD0000005173
HMO 1500 - Flex MD0000005174
HMO 2000 - Flex MD0000005175
HMO 2000 with Coinsurance - Flex MD0000005176
HMO 2500 - Flex MD0000005177
HMO 3500 - Flex MD0000005178
HMO 1750 Core - Flex MD0000005179
HMO 3500 Core - Flex MD0000005180
HMO HSA 2000 - Flex MD0000005181
HMO HSA 3000 - Flex MD0000005182
HMO HSA 3400 - Flex MD0000005183
Focus HMO 25 MD0000005184
Focus HMO 1500 MD0000005185
Focus HMO HSA 3400 MD0000005186

PPO - OFF EXCHANGE with Dental SOB SBC
PPO 25 - Flex MD0000005187
PPO 500 - Flex MD0000005188
PPO 1000 - Flex MD0000005189
PPO 1500 - Flex MD0000005190
PPO 2000 - Flex MD0000005163
PPO 2000 with Coinsurance - Flex MD0000005191
PPO 3500 - Flex MD0000005192
PPO HSA 2000 - Flex MD0000005193
PPO HSA 3000 - Flex MD0000005194
PPO HSA 3400 - Flex MD0000005195
PPO HSA 4500 - Flex MD0000005196

PPO - OFF EXCHANGE without Dental SOB SBC
PPO 25 - Flex MD0000005187
PPO 500 - Flex MD0000005188
PPO 1000 - Flex MD0000005189
PPO 1500 - Flex MD0000005190
PPO 2000 - Flex MD0000005163
PPO 2000 with Coinsurance - Flex MD0000005191
PPO 3500 - Flex MD0000005192
PPO HSA 2000 - Flex MD0000005193
PPO HSA 3000 - Flex MD0000005194
PPO HSA 3400 - Flex MD0000005195
PPO HSA 4500 - Flex MD0000005196