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Home > Members > MA 2016 Individual Market

Schedules of Benefits and SBCs: Massachusetts

Individual Market effective 1/1/16

HMO - ON EXCHANGE without Dental SOB SBC
Tiered Copayment HMO 25 MD0000003803
Best Buy Coinsurance HMO 500 MD0000003804
Best Buy Copayment HMO 1000 MD0000003805
Focus Network MA - Best Buy Copayment HMO 1000 MD0000003806
Best Buy Copayment HMO 2000 MD0000003846
Core Coverage HMO 1750 MD0000003807
Best Buy HSA HMO 3100 MD0000003810
Best Buy HMO 2000 MD0000003808
Best Buy HMO 1000 MD0000003809
Focus Network - MA Best Buy HMO 2000 w/coinsurance MD0000003840

HMO - ON EXCHANGE without Dental - AI/AN -$0 SOB SBC
HMO MD0000003812
HMO MD0000003812
HMO MD0000003812
Focus Network HMO MD0000003813
HMO MD0000003812
HMO MD0000003812
HMO MD0000003812
HMO MD0000003812
HMO MD0000003812
Focus Network HMO MD0000003813

HMO - ON EXCHANGE without Dental - AI/AN -LIMITED SOB SBC
Tiered Copayment HMO 25 MD0000003803
Best Buy Coinsurance HMO 500 MD0000003804
Best Buy Copayment HMO 1000 MD0000003805
Focus Network MA - Best Buy Copayment HMO 1000 MD0000003806
Best Buy Copayment HMO 2000 MD0000003846
Core Coverage HMO 1750 MD0000003807
Best Buy HSA HMO 3100 MD0000003810
Best Buy HMO 2000 MD0000003808
Best Buy HMO 1000 MD0000003809
Focus Network - MA Best Buy HMO 2000 w/coinsurance MD0000003840

PPO - ON EXCHANGE without Dental SOB SBC
Best Buy HSA PPO 3100 MD0000003811
Best Buy HSA PPO 2000 w/coinsurance MD0000003839

PPO - ON EXCHANGE without Dental - AI/AN - $0 SOB SBC
PPO MD0000003814
PPO MD0000003858

PPO - ON EXCHANGE without Dental - AI/AN - LIMITED SOB SBC
Best Buy HSA PPO 3100 MD0000003811
Best Buy HSA PPO 2000 w/coinsurance MD0000003839

HMO - OFF EXCHANGE with Dental SOB SBC
Affordable HMO 20 MD0000003815
Affordable HMO 25 MD0000003816
Affordable HMO 40 MD0000003817
Best Buy HMO 3000 MD0000003818
Core Coverage HMO 3000 MD0000003819
Focus Network - MA Affordable HMO 25 MD0000003820
Focus Network - MA Affordable HMO 40 MD0000003821
Focus Network - MA Best Buy HMO 2000 MD0000003822
Focus Network - MA Best Buy HMO 3000 MD0000003823
Best Buy HSA HMO 2000 MD0000003824
Best Buy HSA HMO 2900 MD0000003825
Best Buy HMO 2000 with Coinsurance MD0000003837
Focus Network - MA Best Buy HMO 1000 MD0000003838
Tiered Copayment HMO 25 MD0000003803
Best Buy Coinsurance HMO 500 MD0000003804
Best Buy Copayment HMO 1000 MD0000003805
Focus Network MA - Best Buy Copayment HMO 1000 MD0000003806
Core Coverage HMO 1750 MD0000003807
Best Buy HSA HMO 3100 MD0000003810
Best Buy HMO 2000 MD0000003808
Best Buy HMO 1000 MD0000003809
Focus Network - MA Best Buy HMO 2000 w/coinsurance MD0000003840

HMO - OFF EXCHANGE without Dental SOB SBC
Affordable HMO 20 MD0000003815
Affordable HMO 25 MD0000003816
Affordable HMO 40 MD0000003817
Best Buy HMO 3000 MD0000003818
Core Coverage HMO 3000 MD0000003819
Focus Network - MA Affordable HMO 25 MD0000003820
Focus Network - MA Affordable HMO 40 MD0000003821
Focus Network - MA Best Buy HMO 2000 MD0000003822
Focus Network - MA Best Buy HMO 3000 MD0000003823
Best Buy HSA HMO 2000 MD0000003824
Best Buy HSA HMO 2900 MD0000003825
Best Buy HMO 2000 with Coinsurance MD0000003837
Focus Network - MA Best Buy HMO 1000 MD0000003838
Tiered Copayment HMO 25 MD0000003803
Best Buy Coinsurance HMO 500 MD0000003804
Best Buy Copayment HMO 1000 MD0000003805
Focus Network MA - Best Buy Copayment HMO 1000 MD0000003806
Best Buy Copayment HMO 2000 MD0000003846
Core Coverage HMO 1750 MD0000003807
Best Buy HSA HMO 3100 MD0000003810
Best Buy HMO 2000 MD0000003808
Best Buy HMO 1000 MD0000003809
Focus Network - MA Best Buy HMO 2000 w/coinsurance MD0000003840

PPO - OFF EXCHANGE with Dental SOB SBC
Affordable PPO 20 MD0000003826
Affordable PPO 25 MD0000003827
Affordable PPO 40 MD0000003828
Best Buy PPO 1000 MD0000003829
Best Buy PPO 2000 MD0000003830
Best Buy PPO 3000 MD0000003831
Best Buy PPO 2000 w/ coinsurance MD0000003833
Best Buy HSA PPO 2000 MD0000003834
Best Buy HSA PPO 2900 MD0000003835
Best Buy HSA PPO 4500 MD0000003841
Best Buy HSA PPO 3100 MD0000003811
Best Buy HSA PPO 2000 w/coinsurance MD0000003839

PPO - OFF EXCHANGE without Dental SOB SBC
Affordable PPO 20 MD0000003826
Affordable PPO 25 MD0000003827
Affordable PPO 40 MD0000003828
Best Buy PPO 1000 MD0000003829
Best Buy PPO 2000 MD0000003830
Best Buy PPO 3000 MD0000003831
Best Buy PPO 2000 w/ coinsurance MD0000003833
Best Buy HSA PPO 2000 MD0000003834
Best Buy HSA PPO 2900 MD0000003835
Best Buy HSA PPO 4500 MD0000003841
Best Buy HSA PPO 3100 MD0000003811
Best Buy HSA PPO 2000 w/coinsurance MD0000003839