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

Schedules of Benefits and SBCs: Connecticut

Small Group effective 1/1/18

OAH SOB SBC
Best Buy HMO Hospital 2000 MD0000004513
Best Buy HMO 2000 with Coinsurance MD0000004518
HMO Copay 25/35 MD0000004520
Best Buy HMO 5000 with Coinsurance MD0000004521
Best Buy HSA HMO 4000 with Coinsurance MD0000004522
Best Buy HSA HMO 3000 MD0000004523

PPO SOB SBC
Best Buy PPO 1500 with Coinsurance MD0000004514
PPO Copay 25/35 MD0000004519
Best Buy PPO 3500 MD0000004524
Best Buy PPO 3 Free 3300 MD0000004525
Best Buy HSA PPO 2700 90/70 MD0000004526
Best Buy HSA PPO 2700 MD0000004527
Best Buy HSA PPO 5500 MD0000004528
Best Buy PPO Hospital 1200 MD0000004533
Best Buy PPO 3500 - with Coinsurance MD0000004534
Best Buy PPO Hospital 2500 - CB MD0000004535
Best Buy PPO 3250 - CB MD0000004536
Best Buy HSA PPO 2800 - CB MD0000004537
Best Buy HSA PPO 3500 - CB MD0000004538
Best Buy HSA PPO 5000 - CB MD0000004539
Best Buy PPO Hospital 1500 - CB MD0000004540
Best Buy PPO 4000 - CB MD0000004541
Best Buy HSA PPO 4250 - CB MD0000004542
Best Buy HSA PPO 6500 - CB MD0000004543
Best Buy PPO 1500 MD0000004544
Best Buy PPO 3750 - CB MD0000004545