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Home > Members > MA 2019 Individual Market

Schedules of Benefits and SBCs: Massachusetts

Individual Market effective 1/1/19

HMO - ON EXCHANGE with Dental SOB SBC
Standard Platinum MD0000004922
Standard High Gold MD0000004924
Standard Low Gold MD0000004925
Standard Silver MD0000004926
Stanard High Bronze MD0000004928

HMO - ON EXCHANGE with Dental - AI/AN - $0 SOB SBC
HMO MD0000004923
HMO MD0000004923
HMO MD0000004923
HMO MD0000004923
HMO MD0000004923

HMO - ON EXCHANGE with Dental - AI/AN - LIMITED SOB SBC
Standard Platinum MD0000004922
Standard High Gold MD0000004924
Standard Low Gold MD0000004925
Standard Silver MD0000004926
Stanard High Bronze MD0000004928

HMO - OFF EXCHANGE with Dental SOB SBC
Standard Platinum MD0000004922
Standard High Gold MD0000004924
Standard Low Gold MD0000004925
Standard Silver MD0000004926
Stanard High Bronze MD0000004928
HMO 25 - Flex MD0000004934
Focus HMO 25 MD0000004949
HMO 500 - Flex MD0000004935
HMO 1000 - Flex MD0000004936
HMO 1000 with Coinsurance - Flex MD0000004937
HMO 2000 - Flex MD0000004939
HMO 2000 with Coinsurance - Flex MD0000004940
HMO 1750 Core - Flex MD0000004943
HMO 3250 Core - Flex MD0000004944
HMO HSA 3100 - Flex MD0000004948
Focus HMO HSA 3100 MD0000004950
HMO 2000 with Copayment - Flex MD0000004941
HMO 3250 - Flex MD0000004942
HMO HSA 2000 - Flex MD0000004945
HMO HSA 2000 with Coinsurance - Flex MD0000004946
HMO HSA 3000 - Flex MD0000004947
HMO 1500 - Flex MD0000004938

HMO - OFF EXCHANGE without Dental SOB SBC
HMO 25 - Flex MD0000004934
Focus HMO 25 MD0000004949
HMO 500 - Flex MD0000004935
HMO 1000 - Flex MD0000004936
HMO 1000 with Coinsurance - Flex MD0000004937
HMO 2000 - Flex MD0000004939
HMO 2000 with Coinsurance - Flex MD0000004940
HMO 1750 Core - Flex MD0000004943
HMO 3250 Core - Flex MD0000004944
HMO HSA 3100 - Flex MD0000004948
Focus HMO HSA 3100 MD0000004950
HMO 2000 with Copayment - Flex MD0000004941
HMO 3250 - Flex MD0000004942
HMO HSA 2000 - Flex MD0000004945
HMO HSA 2000 with Coinsurance - Flex MD0000004946
HMO HSA 3000 - Flex MD0000004947
HMO 1500 - Flex MD0000004938

PPO - OFF EXCHANGE with Dental SOB SBC
PPO 25 - Flex MD0000004951
PPO 500 - Flex MD0000004952
PPO 1000 - Flex MD0000004953
PPO 1000 with Coinsurance - Flex MD0000004954
PPO 2000 - Flex MD0000004933
PPO 2000 with Coinsurance - Flex MD0000004956
PPO HSA 3100 - Flex MD0000004962
PPO HSA 4500 - Flex MD0000004963
PPO 2000 with Copayment - Flex MD0000004957
PPO 3250 - Flex MD0000004958
PPO HSA 2000 - Flex MD0000004959
PPO HSA 2000 with Coinsurance - Flex MD0000004960
PPO HSA 3000 - Flex MD0000004961
PPO 1500 - Flex MD0000004955

PPO - OFF EXCHANGE without Dental SOB SBC
PPO 25 - Flex MD0000004951
PPO 500 - Flex MD0000004952
PPO 1000 - Flex MD0000004953
PPO 1000 with Coinsurance - Flex MD0000004954
PPO 2000 - Flex MD0000004933
PPO 2000 with Coinsurance - Flex MD0000004956
PPO HSA 3100 - Flex MD0000004962
PPO HSA 4500 - Flex MD0000004963
PPO 2000 with Copayment - Flex MD0000004957
PPO 3250 - Flex MD0000004958
PPO HSA 2000 - Flex MD0000004959
PPO HSA 2000 with Coinsurance - Flex MD0000004960
PPO HSA 3000 - Flex MD0000004961
PPO 1500 - Flex MD0000004955