Schedules of Benefits and SBCs: Maine

Individual Market effective 1/1/24

HMO - OFF EXCHANGE with Dental	SOB	SBC
Clear Choice HMO Gold 1500 MD0000201165	Show Clear Choice HMO Gold 1500 SOB	Show Clear Choice HMO Gold 1500 SBC

RX: RX0000201092 Vision: VS0000201056
Clear Choice HMO Gold 2500 MD0000201167	Show Clear Choice HMO Gold 2500 SOB	Show Clear Choice HMO Gold 2500 SBC

RX: RX0000201094 Vision: VS0000201056
Clear Choice HMO Silver 3500 MD0000201168	Show Clear Choice HMO Silver 3500 SOB	Show Clear Choice HMO Silver 3500 SBC

RX: RX0000201095 Vision: VS0000201058
Clear Choice HMO Silver 4200 MD0000201171	Show Clear Choice HMO Silver 4200 SOB	Show Clear Choice HMO Silver 4200 SBC

RX: RX0000201096 Vision: VS0000201058
Clear Choice HMO Silver 5500 MD0000201173	Show Clear Choice HMO Silver 5500 SOB	Show Clear Choice HMO Silver 5500 SBC

RX: RX0000201127 Vision: VS0000201059
Clear Choice HMO Bronze 7500 MD0000201174	Show Clear Choice HMO Bronze 7500 SOB	Show Clear Choice HMO Bronze 7500 SBC

RX: RX0000201098 Vision: VS0000201060
Clear Choice HMO Bronze 9450 MD0000201175	Show Clear Choice HMO Bronze 9450 SOB	Show Clear Choice HMO Bronze 9450 SBC

RX: RX0000201099 Vision: VS0000201060
Clear Choice HMO Catastrophic 9450 MD0000201176	Show Clear Choice HMO Catastrophic 9450 SOB	Show Clear Choice HMO Catastrophic 9450 SBC

RX: RX0000201100 Vision: VS0000201060
Clear Choice Maine's Choice Plus HMO Gold 1500 MD0000201185	Show Clear Choice Maine's Choice Plus HMO Gold 1500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 1500 SBC

RX: RX0000201092 Vision: VS0000201056
Clear Choice Maine's Choice Plus HMO Gold 2500 MD0000201186	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SBC

RX: RX0000201094 Vision: VS0000201056
Clear Choice Maine's Choice Plus HMO Silver 3000 MD0000201188	Show Clear Choice Maine's Choice Plus HMO Silver 3000 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3000 SBC

RX: RX0000201101 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 3500 MD0000201190	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SBC

RX: RX0000201102 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 4200 MD0000201192	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SBC

RX: RX0000201096 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 5500 MD0000201194	Show Clear Choice Maine's Choice Plus HMO Silver 5500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 5500 SBC

RX: RX0000201097 Vision: VS0000201059
Clear Choice Maine's Choice Plus HMO Bronze 7500 MD0000201196	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SOB	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SBC

RX: RX0000201103 Vision: VS0000201060
Clear Choice HMO HSA Silver 4000 MD0000201197	Show Clear Choice HMO HSA Silver 4000 SOB	Show Clear Choice HMO HSA Silver 4000 SBC

RX: RX0000201104 Vision: VS0000201061
Clear Choice HMO HSA Silver 4500 MD0000201198	Show Clear Choice HMO HSA Silver 4500 SOB	Show Clear Choice HMO HSA Silver 4500 SBC

RX: RX0000201105 Vision: VS0000201061
Clear Choice HMO HSA Bronze 5900 MD0000201199	Show Clear Choice HMO HSA Bronze 5900 SOB	Show Clear Choice HMO HSA Bronze 5900 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice HMO HSA Bronze 7200 MD0000201200	Show Clear Choice HMO HSA Bronze 7200 SOB	Show Clear Choice HMO HSA Bronze 7200 SBC

RX: RX0000201107 Vision: VS0000201063
Clear Choice Maine's Choice Plus HMO HSA Silver 4000 MD0000201208	Show Clear Choice Maine's Choice Plus HMO HSA Silver 4000 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Silver 4000 SBC

RX: RX0000201104 Vision: VS0000201061
Clear Choice Maine's Choice Plus HMO HSA Silver 4500 MD0000201209	Show Clear Choice Maine's Choice Plus HMO HSA Silver 4500 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Silver 4500 SBC

RX: RX0000201105 Vision: VS0000201061
Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 MD0000201210	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 MD0000201211	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 SBC

RX: RX0000201141 Vision: VS0000201062
HMO HSA Silver 3300 MD0000201230	Show HMO HSA Silver 3300 SOB	Show HMO HSA Silver 3300 SBC

RX: RX0000201123 Vision: VS0000201062
Maine's Choice Plus HMO HSA Silver 3300 MD0000201231	Show Maine's Choice Plus HMO HSA Silver 3300 SOB	Show Maine's Choice Plus HMO HSA Silver 3300 SBC

RX: RX0000201123 Vision: VS0000201062
HMO HSA Bronze 5400 MD0000201233	Show HMO HSA Bronze 5400 SOB	Show HMO HSA Bronze 5400 SBC

RX: RX0000201124 Vision: VS0000201073
Maine's Choice Plus HMO HSA Bronze 5400 MD0000201234	Show Maine's Choice Plus HMO HSA Bronze 5400 SOB	Show Maine's Choice Plus HMO HSA Bronze 5400 SBC

RX: RX0000201124 Vision: VS0000201073
HMO Silver 6500 MD0000201235	Show HMO Silver 6500 SOB	Show HMO Silver 6500 SBC

RX: RX0000201125 Vision: VS0000201058
Maine's Choice Plus HMO Silver 6500 MD0000201236	Show Maine's Choice Plus HMO Silver 6500 SOB	Show Maine's Choice Plus HMO Silver 6500 SBC

RX: RX0000201125 Vision: VS0000201058
Virtual Choice HMO Silver 6500 MD0000201238	Show Virtual Choice HMO Silver 6500 SOB	Show Virtual Choice HMO Silver 6500 SBC

RX: RX0000201125 Vision: VS0000201058

HMO - OFF EXCHANGE without Dental	SOB	SBC
Clear Choice HMO Gold 1500 MD0000201165	Show Clear Choice HMO Gold 1500 SOB	Show Clear Choice HMO Gold 1500 SBC

RX: RX0000201092 Vision: VS0000201056
Clear Choice HMO Gold 2500 MD0000201167	Show Clear Choice HMO Gold 2500 SOB	Show Clear Choice HMO Gold 2500 SBC

RX: RX0000201094 Vision: VS0000201056
Clear Choice HMO Silver 3500 MD0000201169	Show Clear Choice HMO Silver 3500 SOB	Show Clear Choice HMO Silver 3500 SBC

RX: RX0000201095 Vision: VS0000201058
Clear Choice HMO Silver 4200 MD0000201170	Show Clear Choice HMO Silver 4200 SOB	Show Clear Choice HMO Silver 4200 SBC

RX: RX0000201096 Vision: VS0000201058
Clear Choice HMO Silver 5500 MD0000201172	Show Clear Choice HMO Silver 5500 SOB	Show Clear Choice HMO Silver 5500 SBC

RX: RX0000201127 Vision: VS0000201059
Clear Choice HMO Bronze 7500 MD0000201174	Show Clear Choice HMO Bronze 7500 SOB	Show Clear Choice HMO Bronze 7500 SBC

RX: RX0000201098 Vision: VS0000201060
Clear Choice HMO Bronze 9450 MD0000201175	Show Clear Choice HMO Bronze 9450 SOB	Show Clear Choice HMO Bronze 9450 SBC

RX: RX0000201099 Vision: VS0000201060
Clear Choice HMO Catastrophic 9450 MD0000201176	Show Clear Choice HMO Catastrophic 9450 SOB	Show Clear Choice HMO Catastrophic 9450 SBC

RX: RX0000201100 Vision: VS0000201060
Clear Choice Maine's Choice Plus HMO Gold 1500 MD0000201185	Show Clear Choice Maine's Choice Plus HMO Gold 1500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 1500 SBC

RX: RX0000201092 Vision: VS0000201056
Clear Choice Maine's Choice Plus HMO Gold 2500 MD0000201186	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SBC

RX: RX0000201094 Vision: VS0000201056
Clear Choice Maine's Choice Plus HMO Silver 3000 MD0000201189	Show Clear Choice Maine's Choice Plus HMO Silver 3000 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3000 SBC

RX: RX0000201101 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 3500 MD0000201191	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SBC

RX: RX0000201102 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 4200 MD0000201193	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SBC

RX: RX0000201096 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 5500 MD0000201195	Show Clear Choice Maine's Choice Plus HMO Silver 5500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 5500 SBC

RX: RX0000201097 Vision: VS0000201059
Clear Choice Maine's Choice Plus HMO Bronze 7500 MD0000201196	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SOB	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SBC

RX: RX0000201103 Vision: VS0000201060
Clear Choice HMO HSA Silver 4000 MD0000201197	Show Clear Choice HMO HSA Silver 4000 SOB	Show Clear Choice HMO HSA Silver 4000 SBC

RX: RX0000201104 Vision: VS0000201061
Clear Choice HMO HSA Silver 4500 MD0000201198	Show Clear Choice HMO HSA Silver 4500 SOB	Show Clear Choice HMO HSA Silver 4500 SBC

RX: RX0000201105 Vision: VS0000201061
Clear Choice HMO HSA Bronze 5900 MD0000201199	Show Clear Choice HMO HSA Bronze 5900 SOB	Show Clear Choice HMO HSA Bronze 5900 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice HMO HSA Bronze 7200 MD0000201200	Show Clear Choice HMO HSA Bronze 7200 SOB	Show Clear Choice HMO HSA Bronze 7200 SBC

RX: RX0000201107 Vision: VS0000201063
Clear Choice Maine's Choice Plus HMO HSA Silver 4000 MD0000201208	Show Clear Choice Maine's Choice Plus HMO HSA Silver 4000 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Silver 4000 SBC

RX: RX0000201104 Vision: VS0000201061
Clear Choice Maine's Choice Plus HMO HSA Silver 4500 MD0000201209	Show Clear Choice Maine's Choice Plus HMO HSA Silver 4500 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Silver 4500 SBC

RX: RX0000201105 Vision: VS0000201061
Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 MD0000201210	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 MD0000201211	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 SBC

RX: RX0000201141 Vision: VS0000201062
HMO HSA Silver 3300 MD0000201230	Show HMO HSA Silver 3300 SOB	Show HMO HSA Silver 3300 SBC

RX: RX0000201123 Vision: VS0000201062
Maine's Choice Plus HMO HSA Silver 3300 MD0000201231	Show Maine's Choice Plus HMO HSA Silver 3300 SOB	Show Maine's Choice Plus HMO HSA Silver 3300 SBC

RX: RX0000201123 Vision: VS0000201062
HMO HSA Bronze 5400 MD0000201233	Show HMO HSA Bronze 5400 SOB	Show HMO HSA Bronze 5400 SBC

RX: RX0000201124 Vision: VS0000201073
Maine's Choice Plus HMO HSA Bronze 5400 MD0000201234	Show Maine's Choice Plus HMO HSA Bronze 5400 SOB	Show Maine's Choice Plus HMO HSA Bronze 5400 SBC

RX: RX0000201124 Vision: VS0000201073
HMO Silver 6500 MD0000201235	Show HMO Silver 6500 SOB	Show HMO Silver 6500 SBC

RX: RX0000201125 Vision: VS0000201058
Maine's Choice Plus HMO Silver 6500 MD0000201236	Show Maine's Choice Plus HMO Silver 6500 SOB	Show Maine's Choice Plus HMO Silver 6500 SBC

RX: RX0000201125 Vision: VS0000201058
Virtual Choice HMO Silver 6500 MD0000201238	Show Virtual Choice HMO Silver 6500 SOB	Show Virtual Choice HMO Silver 6500 SBC

RX: RX0000201125 Vision: VS0000201058

HMO - ON EXCHANGE without Dental	SOB	SBC
Clear Choice HMO Gold 1500 MD0000201165	Show Clear Choice HMO Gold 1500 SOB	Show Clear Choice HMO Gold 1500 SBC

RX: RX0000201092 Vision: VS0000201056
Clear Choice HMO Gold 2500 MD0000201167	Show Clear Choice HMO Gold 2500 SOB	Show Clear Choice HMO Gold 2500 SBC

RX: RX0000201094 Vision: VS0000201056
Clear Choice HMO Silver 3500 MD0000201169	Show Clear Choice HMO Silver 3500 SOB	Show Clear Choice HMO Silver 3500 SBC

RX: RX0000201095 Vision: VS0000201058
Clear Choice HMO Silver 5500 MD0000201172	Show Clear Choice HMO Silver 5500 SOB	Show Clear Choice HMO Silver 5500 SBC

RX: RX0000201127 Vision: VS0000201059
Clear Choice HMO Bronze 7500 MD0000201174	Show Clear Choice HMO Bronze 7500 SOB	Show Clear Choice HMO Bronze 7500 SBC

RX: RX0000201098 Vision: VS0000201060
Clear Choice HMO Bronze 9450 MD0000201175	Show Clear Choice HMO Bronze 9450 SOB	Show Clear Choice HMO Bronze 9450 SBC

RX: RX0000201099 Vision: VS0000201060
Clear Choice HMO Catastrophic 9450 MD0000201176	Show Clear Choice HMO Catastrophic 9450 SOB	Show Clear Choice HMO Catastrophic 9450 SBC

RX: RX0000201100 Vision: VS0000201060
Clear Choice Maine's Choice Plus HMO Gold 2500 MD0000201186	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SBC

RX: RX0000201094 Vision: VS0000201056
Clear Choice Maine's Choice Plus HMO Silver 3000 MD0000201189	Show Clear Choice Maine's Choice Plus HMO Silver 3000 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3000 SBC

RX: RX0000201101 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 3500 MD0000201191	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SBC

RX: RX0000201102 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 4200 MD0000201193	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SBC

RX: RX0000201096 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 5500 MD0000201195	Show Clear Choice Maine's Choice Plus HMO Silver 5500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 5500 SBC

RX: RX0000201097 Vision: VS0000201059
Clear Choice Maine's Choice Plus HMO Bronze 7500 MD0000201196	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SOB	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SBC

RX: RX0000201103 Vision: VS0000201060
Clear Choice HMO HSA Bronze 5900 MD0000201199	Show Clear Choice HMO HSA Bronze 5900 SOB	Show Clear Choice HMO HSA Bronze 5900 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice HMO HSA Bronze 7200 MD0000201200	Show Clear Choice HMO HSA Bronze 7200 SOB	Show Clear Choice HMO HSA Bronze 7200 SBC

RX: RX0000201107 Vision: VS0000201063
Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 MD0000201210	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 5900 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 MD0000201211	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 SBC

RX: RX0000201141 Vision: VS0000201062
HMO HSA Bronze 5400 MD0000201233	Show HMO HSA Bronze 5400 SOB	Show HMO HSA Bronze 5400 SBC

RX: RX0000201124 Vision: VS0000201073
Maine's Choice Plus HMO HSA Bronze 5400 MD0000201234	Show Maine's Choice Plus HMO HSA Bronze 5400 SOB	Show Maine's Choice Plus HMO HSA Bronze 5400 SBC

RX: RX0000201124 Vision: VS0000201073

HMO - ON EXCHANGE without Dental - AI/AN - limited	SOB	SBC
Clear Choice HMO Gold 1500 MD0000201165	Show Clear Choice HMO Gold 1500 SOB	Show Clear Choice HMO Gold 1500 SBC

RX: RX0000201092 Vision: VS0000201056
Clear Choice HMO Gold 2500 MD0000201167	Show Clear Choice HMO Gold 2500 SOB	Show Clear Choice HMO Gold 2500 SBC

RX: RX0000201094 Vision: VS0000201056
Clear Choice HMO Silver 3500 MD0000201169	Show Clear Choice HMO Silver 3500 SOB	Show Clear Choice HMO Silver 3500 SBC

RX: RX0000201095 Vision: VS0000201058
Clear Choice HMO Silver 5500 MD0000201172	Show Clear Choice HMO Silver 5500 SOB	Show Clear Choice HMO Silver 5500 SBC

RX: RX0000201127 Vision: VS0000201059
Clear Choice HMO Bronze 7500 MD0000201174	Show Clear Choice HMO Bronze 7500 SOB	Show Clear Choice HMO Bronze 7500 SBC

RX: RX0000201098 Vision: VS0000201060
Clear Choice HMO Bronze 9450 MD0000201175	Show Clear Choice HMO Bronze 9450 SOB	Show Clear Choice HMO Bronze 9450 SBC

RX: RX0000201099 Vision: VS0000201060
Clear Choice Maine's Choice Plus HMO Gold 2500 MD0000201186	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SBC

RX: RX0000201094 Vision: VS0000201056
Clear Choice Maine's Choice Plus HMO Silver 3000 MD0000201189	Show Clear Choice Maine's Choice Plus HMO Silver 3000 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3000 SBC

RX: RX0000201101 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 3500 MD0000201191	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SBC

RX: RX0000201102 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 4200 MD0000201193	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SBC

RX: RX0000201096 Vision: VS0000201058
Clear Choice Maine's Choice Plus HMO Silver 5500 MD0000201195	Show Clear Choice Maine's Choice Plus HMO Silver 5500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 5500 SBC

RX: RX0000201097 Vision: VS0000201059
Clear Choice Maine's Choice Plus HMO Bronze 7500 MD0000201196	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SOB	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SBC

RX: RX0000201103 Vision: VS0000201060
Clear Choice HMO Bronze 5900 MD0000201257	Show Clear Choice HMO Bronze 5900 SOB	Show Clear Choice HMO Bronze 5900 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice HMO Bronze 7200 MD0000201258	Show Clear Choice HMO Bronze 7200 SOB	Show Clear Choice HMO Bronze 7200 SBC

RX: RX0000201107 Vision: VS0000201063
Clear Choice Maine's Choice Plus HMO Bronze 5900 MD0000201260	Show Clear Choice Maine's Choice Plus HMO Bronze 5900 SOB	Show Clear Choice Maine's Choice Plus HMO Bronze 5900 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice Maine's Choice Plus HMO Bronze 6300 MD0000201261	Show Clear Choice Maine's Choice Plus HMO Bronze 6300 SOB	Show Clear Choice Maine's Choice Plus HMO Bronze 6300 SBC

RX: RX0000201106 Vision: VS0000201062
HMO Bronze 5400 MD0000201259	Show HMO Bronze 5400 SOB	Show HMO Bronze 5400 SBC

RX: RX0000201124 Vision: VS0000201073
Maine's Choice Plus HMO Bronze 5400 MD0000201262	Show Maine's Choice Plus HMO Bronze 5400 SOB	Show Maine's Choice Plus HMO Bronze 5400 SBC

RX: RX0000201124 Vision: VS0000201073

HMO - ON EXCHANGE without Dental - AI/AN - $0	SOB	SBC
HMO CSR 100 MD0000201166	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
HMO CSR 100 MD0000201166	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
HMO CSR 100 MD0000201166	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
HMO CSR 100 MD0000201166	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
HMO CSR 100 MD0000201166	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
HMO CSR 100 MD0000201166	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
Maine's Choice Plus HMO CSR 100 MD0000201187	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
Maine's Choice Plus HMO CSR 100 MD0000201187	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
Maine's Choice Plus HMO CSR 100 MD0000201187	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
Maine's Choice Plus HMO CSR 100 MD0000201187	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
Maine's Choice Plus HMO CSR 100 MD0000201187	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
Maine's Choice Plus HMO CSR 100 MD0000201187	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
HMO CSR 100 MD0000201166	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
Maine's Choice Plus HMO CSR 100 MD0000201187	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
HMO CSR 100 MD0000201166	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
HMO CSR 100 MD0000201166	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
Maine's Choice Plus HMO CSR 100 MD0000201187	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057
Maine's Choice Plus HMO CSR 100 MD0000201187	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201093 Vision: VS0000201057

POS - OFF EXCHANGE with Dental	SOB	SBC
Clear Choice POS Silver 3000 MD0000201177	Show Clear Choice POS Silver 3000 SOB	Show Clear Choice POS Silver 3000 SBC

RX: RX0000201126 Vision: VS0000201058
Clear Choice POS Silver 5500 MD0000201178	Show Clear Choice POS Silver 5500 SOB	Show Clear Choice POS Silver 5500 SBC

RX: RX0000201127 Vision: VS0000201059
Clear Choice POS HSA Silver 4500 MD0000201201	Show Clear Choice POS HSA Silver 4500 SOB	Show Clear Choice POS HSA Silver 4500 SBC

RX: RX0000201105 Vision: VS0000201061
Clear Choice POS HSA Bronze 6300 MD0000201202	Show Clear Choice POS HSA Bronze 6300 SOB	Show Clear Choice POS HSA Bronze 6300 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice POS HSA Bronze 7200 MD0000201203	Show Clear Choice POS HSA Bronze 7200 SOB	Show Clear Choice POS HSA Bronze 7200 SBC

RX: RX0000201107 Vision: VS0000201063

POS - OFF EXCHANGE without Dental	SOB	SBC
Clear Choice POS Silver 3000 MD0000201177	Show Clear Choice POS Silver 3000 SOB	Show Clear Choice POS Silver 3000 SBC

RX: RX0000201126 Vision: VS0000201058
Clear Choice POS Silver 5500 MD0000201178	Show Clear Choice POS Silver 5500 SOB	Show Clear Choice POS Silver 5500 SBC

RX: RX0000201127 Vision: VS0000201059
Clear Choice POS HSA Silver 4500 MD0000201201	Show Clear Choice POS HSA Silver 4500 SOB	Show Clear Choice POS HSA Silver 4500 SBC

RX: RX0000201105 Vision: VS0000201061
Clear Choice POS HSA Bronze 6300 MD0000201202	Show Clear Choice POS HSA Bronze 6300 SOB	Show Clear Choice POS HSA Bronze 6300 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice POS HSA Bronze 7200 MD0000201203	Show Clear Choice POS HSA Bronze 7200 SOB	Show Clear Choice POS HSA Bronze 7200 SBC

RX: RX0000201107 Vision: VS0000201063

PPO - OFF EXCHANGE with Dental	SOB	SBC
Clear Choice PPO Gold 1500 MD0000201179	Show Clear Choice PPO Gold 1500 SOB	Show Clear Choice PPO Gold 1500 SBC

RX: RX0000201092 Vision: VS0000201056
Clear Choice PPO Gold 2500 MD0000201180	Show Clear Choice PPO Gold 2500 SOB	Show Clear Choice PPO Gold 2500 SBC

RX: RX0000201094 Vision: VS0000201056
Clear Choice PPO Silver 3500 MD0000201181	Show Clear Choice PPO Silver 3500 SOB	Show Clear Choice PPO Silver 3500 SBC

RX: RX0000201095 Vision: VS0000201058
Clear Choice PPO Silver 4200 MD0000201182	Show Clear Choice PPO Silver 4200 SOB	Show Clear Choice PPO Silver 4200 SBC

RX: RX0000201096 Vision: VS0000201058
Clear Choice PPO Silver 5500 MD0000201183	Show Clear Choice PPO Silver 5500 SOB	Show Clear Choice PPO Silver 5500 SBC

RX: RX0000201127 Vision: VS0000201059
Clear Choice PPO Bronze 7500 MD0000201184	Show Clear Choice PPO Bronze 7500 SOB	Show Clear Choice PPO Bronze 7500 SBC

RX: RX0000201098 Vision: VS0000201060
Clear Choice PPO HSA Silver 4000 MD0000201204	Show Clear Choice PPO HSA Silver 4000 SOB	Show Clear Choice PPO HSA Silver 4000 SBC

RX: RX0000201104 Vision: VS0000201061
Clear Choice PPO HSA Silver 4500 MD0000201205	Show Clear Choice PPO HSA Silver 4500 SOB	Show Clear Choice PPO HSA Silver 4500 SBC

RX: RX0000201105 Vision: VS0000201061
Clear Choice PPO HSA Bronze 5900 MD0000201206	Show Clear Choice PPO HSA Bronze 5900 SOB	Show Clear Choice PPO HSA Bronze 5900 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice PPO HSA Bronze 7200 MD0000201207	Show Clear Choice PPO HSA Bronze 7200 SOB	Show Clear Choice PPO HSA Bronze 7200 SBC

RX: RX0000201107 Vision: VS0000201063
PPO HSA Silver 3300 MD0000201232	Show PPO HSA Silver 3300 SOB	Show PPO HSA Silver 3300 SBC

RX: RX0000201123 Vision: VS0000201062
PPO Silver 6500 MD0000201237	Show PPO Silver 6500 SOB	Show PPO Silver 6500 SBC

RX: RX0000201125 Vision: VS0000201058

PPO - OFF EXCHANGE without Dental	SOB	SBC
Clear Choice PPO Gold 1500 MD0000201179	Show Clear Choice PPO Gold 1500 SOB	Show Clear Choice PPO Gold 1500 SBC

RX: RX0000201092 Vision: VS0000201056
Clear Choice PPO Gold 2500 MD0000201180	Show Clear Choice PPO Gold 2500 SOB	Show Clear Choice PPO Gold 2500 SBC

RX: RX0000201094 Vision: VS0000201056
Clear Choice PPO Silver 3500 MD0000201181	Show Clear Choice PPO Silver 3500 SOB	Show Clear Choice PPO Silver 3500 SBC

RX: RX0000201095 Vision: VS0000201058
Clear Choice PPO Silver 4200 MD0000201182	Show Clear Choice PPO Silver 4200 SOB	Show Clear Choice PPO Silver 4200 SBC

RX: RX0000201096 Vision: VS0000201058
Clear Choice PPO Silver 5500 MD0000201183	Show Clear Choice PPO Silver 5500 SOB	Show Clear Choice PPO Silver 5500 SBC

RX: RX0000201127 Vision: VS0000201059
Clear Choice PPO Bronze 7500 MD0000201184	Show Clear Choice PPO Bronze 7500 SOB	Show Clear Choice PPO Bronze 7500 SBC

RX: RX0000201098 Vision: VS0000201060
Clear Choice PPO HSA Silver 4000 MD0000201204	Show Clear Choice PPO HSA Silver 4000 SOB	Show Clear Choice PPO HSA Silver 4000 SBC

RX: RX0000201104 Vision: VS0000201061
Clear Choice PPO HSA Silver 4500 MD0000201205	Show Clear Choice PPO HSA Silver 4500 SOB	Show Clear Choice PPO HSA Silver 4500 SBC

RX: RX0000201105 Vision: VS0000201061
Clear Choice PPO HSA Bronze 5900 MD0000201206	Show Clear Choice PPO HSA Bronze 5900 SOB	Show Clear Choice PPO HSA Bronze 5900 SBC

RX: RX0000201106 Vision: VS0000201062
Clear Choice PPO HSA Bronze 7200 MD0000201207	Show Clear Choice PPO HSA Bronze 7200 SOB	Show Clear Choice PPO HSA Bronze 7200 SBC

RX: RX0000201107 Vision: VS0000201063
PPO HSA Silver 3300 MD0000201232	Show PPO HSA Silver 3300 SOB	Show PPO HSA Silver 3300 SBC

RX: RX0000201123 Vision: VS0000201062
PPO Silver 6500 MD0000201237	Show PPO Silver 6500 SOB	Show PPO Silver 6500 SBC

RX: RX0000201125 Vision: VS0000201058

HMO - ON EXCHANGE without Dental - CSR - 73%	SOB	SBC
Clear Choice HMO Silver 3500 CSR 73 MD0000201212	Show Clear Choice HMO Silver 3500 CSR 73 SOB	Show Clear Choice HMO Silver 3500 CSR 73 SBC

RX: RX0000201108 Vision: VS0000201064
Clear Choice HMO Silver 5500 CSR 73 MD0000201215	Show Clear Choice HMO Silver 5500 CSR 73 SOB	Show Clear Choice HMO Silver 5500 CSR 73 SBC

RX: RX0000201111 Vision: VS0000201063
Clear Choice Maine's Choice Plus HMO Silver 3000 CSR 73 MD0000201218	Show Clear Choice Maine's Choice Plus HMO Silver 3000 CSR 73 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3000 CSR 73 SBC

RX: RX0000201129 Vision: VS0000201062
Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 73 MD0000201221	Show Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 73 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 73 SBC

RX: RX0000201115 Vision: VS0000201074
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 73 MD0000201224	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 73 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 73 SBC

RX: RX0000201130 Vision: VS0000201074
Clear Choice Maine's Choice Plus HMO Silver 5500 CSR 73 MD0000201227	Show Clear Choice Maine's Choice Plus HMO Silver 5500 CSR 73 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 5500 CSR 73 SBC

RX: RX0000201120 Vision: VS0000201062

HMO - ON EXCHANGE without Dental - CSR - 87%	SOB	SBC
Clear Choice HMO Silver 3500 CSR 87 MD0000201213	Show Clear Choice HMO Silver 3500 CSR 87 SOB	Show Clear Choice HMO Silver 3500 CSR 87 SBC

RX: RX0000201109 Vision: VS0000201065
Clear Choice HMO Silver 5500 CSR 87 MD0000201216	Show Clear Choice HMO Silver 5500 CSR 87 SOB	Show Clear Choice HMO Silver 5500 CSR 87 SBC

RX: RX0000201112 Vision: VS0000201067
Clear Choice Maine's Choice Plus HMO Silver 3000 CSR 87 MD0000201219	Show Clear Choice Maine's Choice Plus HMO Silver 3000 CSR 87 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3000 CSR 87 SBC

RX: RX0000201113 Vision: VS0000201068
Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 87 MD0000201222	Show Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 87 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 87 SBC

RX: RX0000201116 Vision: VS0000201070
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 87 MD0000201225	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 87 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 87 SBC

RX: RX0000201118 Vision: VS0000201072
Clear Choice Maine's Choice Plus HMO Silver 5500 CSR 87 MD0000201228	Show Clear Choice Maine's Choice Plus HMO Silver 5500 CSR 87 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 5500 CSR 87 SBC

RX: RX0000201121 Vision: VS0000201070

HMO - ON EXCHANGE without Dental - CSR - 94%	SOB	SBC
Clear Choice HMO Silver 3500 CSR 94 MD0000201214	Show Clear Choice HMO Silver 3500 CSR 94 SOB	Show Clear Choice HMO Silver 3500 CSR 94 SBC

RX: RX0000201110 Vision: VS0000201066
Clear Choice HMO Silver 5500 CSR 94 MD0000201217	Show Clear Choice HMO Silver 5500 CSR 94 SOB	Show Clear Choice HMO Silver 5500 CSR 94 SBC

RX: RX0000201128 Vision: VS0000201066
Clear Choice Maine's Choice Plus HMO Silver 3000 CSR 94 MD0000201220	Show Clear Choice Maine's Choice Plus HMO Silver 3000 CSR 94 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3000 CSR 94 SBC

RX: RX0000201114 Vision: VS0000201069
Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 94 MD0000201223	Show Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 94 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 94 SBC

RX: RX0000201117 Vision: VS0000201071
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 94 MD0000201226	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 94 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 94 SBC

RX: RX0000201119 Vision: VS0000201069
Clear Choice Maine's Choice Plus HMO Silver 5500 CSR 94 MD0000201229	Show Clear Choice Maine's Choice Plus HMO Silver 5500 CSR 94 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 5500 CSR 94 SBC

RX: RX0000201122 Vision: VS0000201069

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