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

Schedules of Benefits and SBCs: New Hampshire

Small Group effective 1/1/17

HMO - ON EXCHANGE without Dental SOB SBC
ElevateHealth Silver HMO 4000 MD0000004154
ElevateHealth Silver HMO 3000 with Rx Deductible MD0000004155
ElevateHealth Silver HSA HMO 3000 MD0000004157
Best Buy Gold HMO LP 2000 MD0000004159
Best Buy Silver HMO LP 3000 with Rx Deductible MD0000004161
Best Buy Silver HMO LP 4000 MD0000004162
Best Buy Silver HSA HMO 3000 MD0000004165
Best Buy Bronze HSA HMO 6250 MD0000004166

HMO - OFF EXCHANGE with Dental SOB SBC
ElevateHealth Options Gold 1000 MD0000004200
ElevateHealth Options Silver 3000 MD0000004201
ElevateHealth Silver HMO 5000 MD0000004153
ElevateHealth Silver HMO 4000 MD0000004154
ElevateHealth Silver HMO 3000 with Rx Deductible MD0000004155
ElevateHealth Bronze HSA HMO 5000 MD0000004156
ElevateHealth Silver HSA HMO 3000 MD0000004157
Best Buy Silver HMO LP 3000 MD0000004158
Best Buy Gold HMO LP 2000 MD0000004159
Best Buy Gold HMO LP 1250 MD0000004160
Best Buy Silver HMO LP 3000 with Rx Deductible MD0000004161
Best Buy Silver HMO LP 4000 MD0000004162
Best Buy Silver HMO LP 4000 with Rx Deductible MD0000004163
Best Buy Silver HMO LP 5000 MD0000004164
Best Buy Silver HSA HMO 3000 MD0000004165
Best Buy Bronze HSA HMO 6250 MD0000004166
Best Buy Bronze HSA HMO 5000 MD0000004168

HMO - OFF EXCHANGE without Dental SOB SBC
ElevateHealth Options Gold 1000 MD0000004200
ElevateHealth Options Silver 3000 MD0000004201
ElevateHealth Silver HMO 5000 MD0000004153
ElevateHealth Slver HMO 4000 MD0000004154
ElevateHealth Silver HMO 3000 with Rx Deductible MD0000004155
ElevateHealth Bronze HSA HMO 5000 MD0000004156
ElevateHealth Silver HSA HMO 3000 MD0000004157
Best Buy Silver HMO LP 3000 MD0000004158
Best Buy Gold HMO LP 2000 MD0000004159
Best Buy Gold HMO LP 1250 MD0000004160
Best Buy Silver HMO LP 3000 with Rx Deductible MD0000004161
Best Buy Silver HMO LP 4000 MD0000004162
Best Buy Silver HMO LP 4000 with Rx Deductible MD0000004163
Best Buy Silver HMO LP 5000 MD0000004164
Best Buy Silver HSA HMO 3000 MD0000004165
Best Buy Bronze HSA HMO 6250 MD0000004166
Best Buy Bronze HSA HMO 5000 MD0000004168

PPO - OFF EXCHANGE with Dental SOB SBC
Best Buy Gold PPO LP 1250 MD0000004167
Best Buy Gold PPO LP 2000 MD0000004169
Best Buy Silver PPO LP 3000 MD0000004170
Best Buy Silver PPO LP 4000 MD0000004171
Best Buy Silver HSA PPO 3000 MD0000004172
Best Buy Bronze HSA PPO 5000 MD0000004173
Best Buy Bronze HSA PPO 6250 MD0000004174

PPO - OFF EXCHANGE without Dental SOB SBC
Best Buy Gold PPO LP 1250 MD0000004167
Best Buy Gold PPO LP 2000 MD0000004169
Best Buy Silver PPO LP 3000 MD0000004170
Best Buy Silver PPO LP 4000 MD0000004171
Best Buy Silver HSA PPO 3000 MD0000004172
Best Buy Bronze HSA PPO 5000 MD0000004173
Best Buy Bronze HSA PPO 6250 MD0000004174