2025 Schedules of Benefits and SBCs: Massachusetts

Individual Market effective 1/1/25

HMO - ON EXCHANGE with dental SOBSBC
Standard Platinum - Flex MD0000201392
Standard High Gold MD0000201393
Standard Silver II MD0000201395
Standard High Bronze HSA - Flex MD0000201398
HMO 2000 Value II - Flex MD0000201399
HMO 3500 - Flex MD0000201401
HMO - OFF EXCHANGE with dental SOBSBC
Standard Platinum - Flex MD0000201392
Standard High Gold MD0000201393
Standard Silver MD0000201394
Standard Low Silver HSA - Flex MD0000201404
Standard High Bronze HSA - Flex MD0000201398
HMO 2000 Value II - Flex MD0000201399
HMO 3500 - Flex MD0000201401
HMO 20 - Flex MD0000201427
HMO 500 - Flex MD0000201446
HMO 1000 - Flex MD0000201458
HMO 1500 - Flex MD0000201431
HMO 1500 Value - Flex MD0000201432
HMO 2000 - Flex MD0000201433
HMO 2000 Value - Flex MD0000201436
HMO 2500 - Flex MD0000201434
HMO 3000 - Flex MD0000201437
HMO 4000 - Flex MD0000201445
HMO 5000 - Flex MD0000201438
HMO 6000 Value - Flex MD0000201459
HMO HSA 2000 - Flex MD0000201414
HMO HSA 2500 - Flex MD0000201447
HMO HSA 3000 - Flex MD0000201428
HMO HSA 3400 - Flex MD0000201429
HMO HSA 4000 - Flex MD0000201430
Focus HMO 1000 MD0000201448
Focus HMO 1500 MD0000201449
Focus HMO 2000 MD0000201450
Focus HMO 2500 MD0000201435
Focus HMO 3000 MD0000201451
Focus HMO HSA 3400 MD0000201415
HMO - ON EXCHANGE with dental - AI/AN - Limited SOBSBC
Standard Platinum - Flex MD0000201392
Standard High Gold MD0000201393
Standard Silver II MD0000201395
Standard High Bronze - Flex MD0000201402
HMO 2000 Value II - Flex MD0000201399
HMO 3500 - Flex MD0000201401
HMO - ON EXCHANGE with dental - AI/AN - $0SOBSBC
HMO MD0000201412
HMO MD0000201412
HMO MD0000201412
HMO MD0000201412
HMO MD0000201412
HMO MD0000201412
HMO - ON EXCHANGE with dental - CSR - 94%SOBSBC
Standard ConnectorCare 1 MD0000201413
HMO - ON EXCHANGE with dental - CSR - 87%SOBSBC
Standard ConnectorCare 2 MD0000201396
HMO - ON EXCHANGE with dental - CSR - 73%SOBSBC
Standard ConnectorCare 3 MD0000201397
PPO - OFF EXCHANGE with dental SOBSBC
PPO HSA 2000 - Flex MD0000201400
PPO 20 - Flex MD0000201439
PPO 500 - Flex MD0000201440
PPO 1000 - Flex MD0000201441
PPO 1500 - Flex MD0000201442
PPO 1500 Value - Flex MD0000201452
PPO 2000 - Flex MD0000201443
PPO 2000 Value - Flex MD0000201444
PPO 2500 - Flex MD0000201453
PPO 3000 - Flex MD0000201454
PPO 4000 - Flex MD0000201455
PPO HSA 3000 - Flex MD0000201456
PPO HSA 3400 - Flex MD0000201460
PPO HSA 5000 - Flex MD0000201457
HMO - OFF EXCHANGE without dental SOBSBC
HMO 20 - Flex MD0000201427
HMO 500 - Flex MD0000201446
HMO 1000 - Flex MD0000201458
HMO 1500 - Flex MD0000201431
HMO 1500 Value - Flex MD0000201432
HMO 2000 - Flex MD0000201433
HMO 2000 Value - Flex MD0000201436
HMO 2500 - Flex MD0000201434
HMO 3000 - Flex MD0000201437
HMO 4000 - Flex MD0000201445
HMO 5000 - Flex MD0000201438
HMO 6000 Value - Flex MD0000201459
HMO HSA 2000 - Flex MD0000201414
HMO HSA 2500 - Flex MD0000201447
HMO HSA 3000 - Flex MD0000201428
HMO HSA 3400 - Flex MD0000201429
HMO HSA 4000 - Flex MD0000201430
Focus HMO 1000 MD0000201448
Focus HMO 1500 MD0000201449
Focus HMO 2000 MD0000201450
Focus HMO 2500 MD0000201435
Focus HMO 3000 MD0000201451
Focus HMO HSA 3400 MD0000201415
PPO - OFF EXCHANGE without dental SOBSBC
PPO 20 - Flex MD0000201439
PPO 500 - Flex MD0000201440
PPO 1000 - Flex MD0000201441
PPO 1500 - Flex MD0000201442
PPO 1500 Value - Flex MD0000201452
PPO 2000 - Flex MD0000201443
PPO 2000 Value - Flex MD0000201444
PPO 2500 - Flex MD0000201453
PPO 3000 - Flex MD0000201454
PPO 4000 - Flex MD0000201455
PPO HSA 3000 - Flex MD0000201456
PPO HSA 3400 - Flex MD0000201460
PPO HSA 5000 - Flex MD0000201457