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Home > Broker > Plan Information > Schedules of Benefits and SBCs > Schedule of Benefits and SBCs - ME 2016

Schedules of Benefits and SBCs: Maine

Small Group effective 1/1/16

HMO - ON EXCHANGE without Dental SOB SBC
Maine Difference Deductible Tiered Copayment HMO 1000 MD0000003646
Maine Difference Deductible Tiered Copayment HMO 1500 MD0000003647
Best Buy HSA HMO 5000 MD0000003661
Maine Difference Deductible Tiered Copayment HMO 2500 MD0000003649
Best Buy HSA HMO 3000 MD0000003658
Best Buy HSA HMO 6100 MD0000003663
Maine's ChoiceSM HMO 1250 MD0000003782
Maine's ChoiceSM HMO 2000 MD0000003786
Maine's ChoiceSM HMO 3500 MD0000003793
Maine's ChoiceSM Best Buy HSA HMO 2800 MD0000003789

HMO - OFF EXCHANGE with Dental SOB SBC
Maine Difference Deductible Tiered Copayment HMO 1500 MD0000003647
Maine Difference Deductible Tiered Copayment HMO 2500 MD0000003649
Maine Difference Deductible Tiered Copayment HMO 2500 MD0000003649
Maine Difference Deductible Tiered Copayment HMO 3000 MD0000003650
Maine Difference Deductible Tiered Copayment HMO 3000 MD0000003650
Best Buy HSA HMO 3000 MD0000003658
Best Buy HSA HMO 5000 MD0000003661
Best Buy HSA HMO 6100 MD0000003663
HMO Copayment 2000 MD0000003648
HMO Copayment 2000 MD0000003648
Maine Difference Deductible Tiered Copayment HMO 1000 MD0000003646
Best Buy HSA HMO 4500 MD0000003659
Maine's ChoiceSM HMO 1250 MD0000003782
Maine's ChoiceSM HMO 2000 MD0000003786
Maine's ChoiceSM HMO 3500 MD0000003793
Maine's ChoiceSM Best Buy HSA HMO 2800 MD0000003789
Best Buy HSA HMO 2600 MD0000004131
Maine's ChoiceSM Best Buy HSA HMO 2800 MD0000004142
Best Buy HSA HMO 3500 MD0000004132
Best Buy HSA HMO 3000 MD0000004135
Best Buy HSA HMO 4500 MD0000004136
Best Buy HSA HMO 5000 MD0000004137
Best Buy HSA HMO 6100 MD0000004138

HMO - OFF EXCHANGE without Dental SOB SBC
Maine Difference Deductible Tiered Copayment HMO 1500 MD0000003647
Maine Difference Deductible Tiered Copayment HMO 2500 MD0000003649
Maine Difference Deductible Tiered Copayment HMO 2500 MD0000003649
Maine Difference Deductible Tiered Copayment HMO 3000 MD0000003650
Maine Difference Deductible Tiered Copayment HMO 3000 MD0000003650
Best Buy HSA HMO 3000 MD0000003658
Best Buy HSA HMO 5000 MD0000003661
Best Buy HSA HMO 6100 MD0000003663
HMO Copayment 2000 MD0000003648
HMO Copayment 2000 MD0000003648
Maine Difference Deductible Tiered Copayment HMO 1000 MD0000003646
Best Buy HSA HMO 4500 MD0000003659
Maine's ChoiceSM HMO 1250 MD0000003782
Maine's ChoiceSM HMO 2000 MD0000003786
Maine's ChoiceSM HMO 3500 MD0000003793
Maine's ChoiceSM Best Buy HSA HMO 2800 MD0000003789
Best Buy HSA HMO 2600 MD0000004131
Maine's ChoiceSM Best Buy HSA HMO 2800 MD0000004142
Best Buy HSA HMO 3500 MD0000004132
Best Buy HSA HMO 3000 MD0000004135
Best Buy HSA HMO 4500 MD0000004136
Best Buy HSA HMO 5000 MD0000004137
Best Buy HSA HMO 6100 MD0000004138

PPO - OFF EXCHANGE with Dental SOB SBC
Tiered Copay PPO 1500 MD0000003665
Tiered Copay PPO 2500 MD0000003668
Tiered Copay PPO 2500 MD0000003668
Tiered Copay PPO 3000 MD0000003670
Tiered Copay PPO 3000 MD0000003670
Core Coverage PPO 2500 MD0000003667
Core Coverage PPO 2500 MD0000003667
Best Buy HSA PPO 3000 MD0000003669
Best Buy HSA PPO 5000 MD0000003672
PPO Copayment 2000 MD0000003666
PPO Copayment 2000 MD0000003666
Tiered Copay PPO 1000 MD0000003664
Best Buy HSA PPO 4500 MD0000003671
Best Buy HSA PPO 4500 MD0000004140
Best Buy HSA PPO 5000 MD0000004141
Best Buy HSA PPO 2600 MD0000004133
Best Buy HSA PPO 3500 MD0000004134
Best Buy HSA PPO 3000 MD0000004139

PPO - OFF EXCHANGE without Dental SOB SBC
Tiered Copay PPO 1500 MD0000003665
Tiered Copay PPO 2500 MD0000003668
Tiered Copay PPO 2500 MD0000003668
Tiered Copay PPO 3000 MD0000003670
Tiered Copay PPO 3000 MD0000003670
Core Coverage PPO 2500 MD0000003667
Core Coverage PPO 2500 MD0000003667
Best Buy HSA PPO 3000 MD0000003669
Best Buy HSA PPO 5000 MD0000003672
PPO Copayment 2000 MD0000003666
PPO Copayment 2000 MD0000003666
Tiered Copay PPO 1000 MD0000003664
Best Buy HSA PPO 4500 MD0000003671
Best Buy HSA PPO 4500 MD0000004140
Best Buy HSA PPO 5000 MD0000004141
Best Buy HSA PPO 2600 MD0000004133
Best Buy HSA PPO 3500 MD0000004134
Best Buy HSA PPO 3000 MD0000004139

POS - OFF EXCHANGE with Dental SOB SBC
POS 3000 MD0000004287
HSA POS 5500 MD0000004292
POS 1500 MD0000004450
POS 3750 MD0000004451
POS HSA 3250 MD0000004452

POS - OFF EXCHANGE without Dental SOB SBC
POS 3000 MD0000004287
HSA POS 5500 MD0000004292
POS 1500 MD0000004450
POS 3750 MD0000004451
POS HSA 3250 MD0000004452