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Home > Broker > Plan Information > Schedules of Benefits and SBCs > Schedule of Benefits and SBCs - ME 2017

Schedules of Benefits and SBCs: Maine

Small Group effective 1/1/17

HMO - OFF EXCHANGE with Dental SOB SBC
Core Coverage HMO 2600 MD0000004285
Core Coverage HMO 2600 MD0000004285
Maine Difference HMO 1000 MD0000004232
Maine Difference HMO 1500 MD0000004233
Maine Difference HMO 2600 MD0000004234
Maine Difference HMO 3000 MD0000004235
Maine Difference HMO 3000 MD0000004235
Best Buy HSA HMO 2600 MD0000004236
Best Buy HSA HMO 3000 MD0000004237
Maine Difference HMO 2600 MD0000004234
Best Buy HSA HMO 4750 MD0000004238
Best Buy HSA HMO 5300 MD0000004239
Best Buy HSA HMO 6250 MD0000004240
Best Buy HSA HMO 3500 MD0000004247
Maine's ChoiceSM HMO 1250 MD0000004251
Maine's ChoiceSM HMO 2000 MD0000004252
Maine's ChoiceSM HMO 3500 MD0000004278
Maine's ChoiceSM Best Buy HSA HMO 2800 MD0000004279
Maine Difference HMO 4500 MD0000004323
Maine Difference HMO 5250 MD0000004282

POS - OFF EXCHANGE with Dental SOB SBC
POS 1500 MD0000004286
POS 3000 MD0000004287
POS 3750 MD0000004290
HSA POS 3250 MD0000004291
HSA POS 5500 MD0000004292

PPO - OFF EXCHANGE with Dental SOB SBC
PPO 1000 MD0000004241
PPO 1500 MD0000004242
PPO 2600 MD0000004243
PPO 2600 MD0000004243
PPO 3000 MD0000004244
PPO 3000 MD0000004244
Best Buy HSA PPO 2600 MD0000004245
Best Buy HSA PPO 3500 MD0000004246
Best Buy HSA PPO 3000 MD0000004248
Best Buy HSA PPO 4750 MD0000004249
Best Buy HSA PPO 5300 MD0000004250
PPO 4500 MD0000004324
PPO 5250 MD0000004283
Core Coverage PPO 2600 MD0000004284
Core Coverage PPO 2600 MD0000004284

HMO - OFF EXCHANGE without Dental SOB SBC
Core Coverage HMO 2600 MD0000004285
Core Coverage HMO 2600 MD0000004285
Maine Difference HMO 1000 MD0000004232
Maine Difference HMO 1500 MD0000004233
Maine Difference HMO 2600 MD0000004234
Maine Difference HMO 3000 MD0000004235
Maine Difference HMO 3000 MD0000004235
Best Buy HSA HMO 2600 MD0000004236
Best Buy HSA HMO 3000 MD0000004237
Maine Difference HMO 2600 MD0000004234
Best Buy HSA HMO 4750 MD0000004238
Best Buy HSA HMO 5300 MD0000004239
Best Buy HSA HMO 6250 MD0000004240
Best Buy HSA HMO 3500 MD0000004247
Maine's ChoiceSM HMO 1250 MD0000004251
Maine's ChoiceSM HMO 2000 MD0000004252
Maine's ChoiceSM HMO 3500 MD0000004278
Maine's ChoiceSM Best Buy HSA HMO 2800 MD0000004279
Maine Difference HMO 4500 MD0000004323
Maine Difference HMO 5250 MD0000004282

POS - OFF EXCHANGE without Dental SOB SBC
POS 1500 MD0000004286
POS 3000 MD0000004287
POS 3750 MD0000004290
HSA POS 3250 MD0000004291
HSA POS 5500 MD0000004292

PPO - OFF EXCHANGE without Dental SOB SBC
PPO 1000 MD0000004241
PPO 1500 MD0000004242
PPO 2600 MD0000004243
PPO 2600 MD0000004243
PPO 3000 MD0000004244
PPO 3000 MD0000004244
Best Buy HSA PPO 2600 MD0000004245
Best Buy HSA PPO 3500 MD0000004246
Best Buy HSA PPO 3000 MD0000004248
Best Buy HSA PPO 4750 MD0000004249
Best Buy HSA PPO 5300 MD0000004250
PPO 4500 MD0000004324
PPO 5250 MD0000004283
Core Coverage PPO 2600 MD0000004284
Core Coverage PPO 2600 MD0000004284

HMO - ON EXCHANGE without Dental SOB SBC
Maine Difference HMO 1000 MD0000004232
Maine Difference HMO 1500 MD0000004233
Maine Difference HMO 2600 MD0000004234
Best Buy HSA HMO 3000 MD0000004237
Best Buy HSA HMO 5300 MD0000004239
Best Buy HSA HMO 6250 MD0000004240
Maine's ChoiceSM HMO 1250 MD0000004251
Maine's ChoiceSM HMO 2000 MD0000004252
Maine's ChoiceSM HMO 3500 MD0000004278
Maine's ChoiceSM Best Buy HSA HMO 2800 MD0000004279