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

Schedules of Benefits and SBCs: New Hampshire

Small Group effective 1/1/16

HMO - ON EXCHANGE without Dental SOB SBC
ElevateHealth HMO 2000 MD0000003690
ElevateHealth HMO 4000 MD0000003714
ElevateHealth HSA HMO 6250 MD0000003725
Best Buy Tiered Copayment HMO LP 2000 MD0000003691
ElevateHealth HMO 3000 Low Option MD0000003704
ElevateHealth HSA HMO 3000 MD0000003698
Best Buy Tiered Copayment HMO LP 3000 Low Option MD0000003703
Best Buy Tiered Copayment HMO LP 4000 MD0000003715
Best Buy HSA HMO 6250 MD0000003724
Best Buy HSA HMO 3000 MD0000003697

HMO - OFF EXCHANGE with Dental SOB SBC
ElevateHealth HMO 3000 MD0000003705
Best Buy Tiered Copayment HMO LP 3500 MD0000003707
Best Buy Tiered Copayment HMO LP 4000 MD0000003713
Best Buy Tiered Copayment HMO LP 1250 MD0000003683
ElevateHealth HSA HMO 6250 MD0000003725
ElevateHealth HSA HMO 4000 MD0000003710
ElevateHealth HSA HMO 5000 MD0000003720
ElevateHealth HMO 5000 MD0000003718
ElevateHealth HMO 2000 MD0000003690
ElevateHealth HMO 4000 MD0000003714
ElevateHealth HSA HMO 3000 MD0000003698
NH Core Coverage 3000 MD0000003701
Best Buy HSA HMO 3000 MD0000003697
Best Buy Tiered Copayment HMO LP 2000 MD0000003691
Best Buy Tiered Copayment HMO LP 3000 MD0000003702
Best Buy Tiered Copayment HMO LP 3000 Low Option MD0000003703
Best Buy Tiered Copayment HMO LP 4000 MD0000003715
Best Buy Tiered Copayment HMO LP 4000 Low Option MD0000003708
Best Buy Tiered Copayment HMO LP 5000 MD0000003719
ElevateHealth HMO 3000 Low Option MD0000003704
ElevateHealth HMO 4000 Low Option MD0000003709
Best Buy Tiered Copayment HMO 1250 NetOption LP MD0000003728
Best Buy HSA HMO 4000 MD0000003711
Best Buy HSA HMO 5000 MD0000003721
Best Buy HSA HMO 6250 MD0000003724
ElevateHealth HSA HMO 2600 MD0000003779
Best Buy HSA HMO 2600 MD0000003780

HMO - OFF EXCHANGE without Dental SOB SBC
ElevateHealth HMO 2000 MD0000003690
ElevateHealth HMO 3000 MD0000003705
ElevateHealth HMO 4000 MD0000003714
ElevateHealth HMO 5000 MD0000003718
ElevateHealth HSA HMO 3000 MD0000003698
NH Core Coverage 3000 MD0000003701
Best Buy HSA HMO 3000 MD0000003697
ElevateHealth HSA HMO 4000 MD0000003710
ElevateHealth HSA HMO 5000 MD0000003720
ElevateHealth HSA HMO 6250 MD0000003725
Best Buy Tiered Copayment HMO LP 1250 MD0000003683
Best Buy Tiered Copayment HMO LP 2000 MD0000003691
Best Buy Tiered Copayment HMO LP 3000 MD0000003702
Best Buy Tiered Copayment HMO LP 3500 MD0000003707
Best Buy Tiered Copayment HMO LP 4000 MD0000003713
Best Buy Tiered Copayment HMO LP 3000 Low Option MD0000003703
Best Buy Tiered Copayment HMO LP 4000 MD0000003715
Best Buy Tiered Copayment HMO LP 4000 Low Option MD0000003708
Best Buy Tiered Copayment HMO LP 5000 MD0000003719
ElevateHealth HMO 3000 Low Option MD0000003704
ElevateHealth HMO 4000 Low Option MD0000003709
Best Buy Tiered Copayment HMO 1250 NetOption LP MD0000003728
Best Buy HSA HMO 4000 MD0000003711
Best Buy HSA HMO 5000 MD0000003721
Best Buy HSA HMO 6250 MD0000003724
ElevateHealth HSA HMO 2600 MD0000003779
Best Buy HSA HMO 2600 MD0000003780

PPO - OFF EXCHANGE with Dental SOB SBC
Best Buy HSA PPO 3000 MD0000003740
Best Buy HSA PPO 4000 MD0000003743
Best Buy HSA PPO 4250 MD0000003744
Best Buy HSA PPO 5000 MD0000003747
Best Buy HSA PPO 6250 MD0000003748
Best Buy Tiered Copayment PPO LP 1250 MD0000003733
Best Buy Tiered Copayment PPO LP 2000 MD0000003735
Best Buy Tiered Copayment PPO LP 3000 MD0000003739
Best Buy Tiered Copayment PPO LP 4000 MD0000003742
Best Buy Tiered Copayment PPO LP 5000 MD0000003746
Best Buy HSA PPO 2600 MD0000003781

PPO - OFF EXCHANGE without Dental SOB SBC
Best Buy HSA PPO 3000 MD0000003740
Best Buy HSA PPO 4000 MD0000003743
Best Buy HSA PPO 4250 MD0000003744
Best Buy HSA PPO 5000 MD0000003747
Best Buy HSA PPO 6250 MD0000003748
Best Buy Tiered Copayment PPO LP 1250 MD0000003733
Best Buy Tiered Copayment PPO LP 2000 MD0000003735
Best Buy Tiered Copayment PPO LP 3000 MD0000003739
Best Buy Tiered Copayment PPO LP 4000 MD0000003742
Best Buy Tiered Copayment PPO LP 5000 MD0000003746
Best Buy HSA PPO 2600 MD0000003781