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Home > Broker > Plan Information > Schedules of Benefits and SBCs > Schedule of Benefits and SBCs - NH 2018

Schedules of Benefits and SBCs: New Hampshire

Small Group effective 1/1/18

HMO - OFF EXCHANGE with Dental SOB SBC
Best Buy Gold HMO LP 2000 MD0000004494
Best Buy Gold HMO LP 1250 MD0000004495
Best Buy Silver HMO LP 3000 MD0000004496
Best Buy Silver HMO LP 4000 MD0000004498
Best Buy Silver HMO LP 5000 MD0000004500
ElevateHealth Options Gold HMO 1000 MD0000004501
ElevateHealth Options Silver HMO 3000 MD0000004502
ElevateHealth Silver HMO 4000 MD0000004503
ElevateHealth Silver HMO 5000 MD0000004504
Best Buy Bronze HSA HMO 5000 MD0000004506
Best Buy Bronze HSA HMO 6250 MD0000004508
ElevateHealth Bronze HSA HMO 5000 MD0000004509
ElevateHealth Silver HSA HMO 3000 MD0000004510
Best Buy Silver HSA HMO 3000 MD0000004511
ElevateHealth Silver HSA HMO 3000 with Preventive RX MD0000004515
Best Buy Silver HSA HMO 3000 with Preventive RX MD0000004516
Best Buy Silver HSA HMO 4000 MD0000004529
Best Buy Silver HSA HMO 4000 with Preventive RX MD0000004530

HMO - OFF EXCHANGE without Dental SOB SBC
Best Buy Gold HMO LP 2000 MD0000004494
Best Buy Gold HMO LP 1250 MD0000004495
Best Buy Silver HMO LP 3000 MD0000004496
Best Buy Silver HMO LP 4000 MD0000004498
Best Buy Silver HMO LP 5000 MD0000004500
ElevateHealth Options Gold HMO 1000 MD0000004501
ElevateHealth Options Silver HMO 3000 MD0000004502
ElevateHealth Silver HMO 4000 MD0000004503
ElevateHealth Silver HMO 5000 MD0000004504
Best Buy Bronze HSA HMO 5000 MD0000004506
Best Buy Bronze HSA HMO 6250 MD0000004508
ElevateHealth Bronze HSA HMO 5000 MD0000004509
ElevateHealth Silver HSA HMO 3000 MD0000004510
Best Buy Silver HSA HMO 3000 MD0000004511
ElevateHealth Silver HSA HMO 3000 with Preventive RX MD0000004515
Best Buy Silver HSA HMO 3000 with Preventive RX MD0000004516
Best Buy Silver HSA HMO 4000 MD0000004529
Best Buy Silver HSA HMO 4000 with Preventive RX MD0000004530

PPO - OFF EXCHANGE with Dental SOB SBC
Best Buy Gold PPO LP 1250 MD0000004492
Best Buy Gold PPO LP 2000 MD0000004493
Best Buy Silver PPO LP 3000 MD0000004497
Best Buy Silver PPO LP 4000 MD0000004499
Best Buy Bronze HSA PPO 5000 MD0000004505
Best Buy Bronze HSA PPO 6250 MD0000004507
Best Buy Silver HSA PPO 3000 MD0000004512
Best Buy Silver HSA PPO 3000 with Preventive RX MD0000004517
Best Buy Silver HSA PPO 4000 MD0000004531
Best Buy Silver HSA PPO 4000 with Preventive RX MD0000004532

PPO - OFF EXCHANGE without Dental SOB SBC
Best Buy Gold PPO LP 1250 MD0000004492
Best Buy Gold PPO LP 2000 MD0000004493
Best Buy Silver PPO LP 3000 MD0000004497
Best Buy Silver PPO LP 4000 MD0000004499
Best Buy Bronze HSA PPO 5000 MD0000004505
Best Buy Bronze HSA PPO 6250 MD0000004507
Best Buy Silver HSA PPO 3000 MD0000004512
Best Buy Silver HSA PPO 3000 with Preventive RX MD0000004517
Best Buy Silver HSA PPO 4000 MD0000004531
Best Buy Silver HSA PPO 4000 with Preventive RX MD0000004532