Schedules of Benefits and SBCs: Maine

Individual Market effective 1/1/25

HMO - OFF EXCHANGE with Dental	SOB	SBC
Clear Choice HMO Gold 1500 MD0000201461	Show Clear Choice HMO Gold 1500 SOB	Show Clear Choice HMO Gold 1500 SBC

RX: RX0000201247 Vision: VS0000201176
Clear Choice HMO Gold 2500 MD0000201462	Show Clear Choice HMO Gold 2500 SOB	Show Clear Choice HMO Gold 2500 SBC

RX: RX0000201249 Vision: VS0000201176
Clear Choice HMO Silver 3500 MD0000201463	Show Clear Choice HMO Silver 3500 SOB	Show Clear Choice HMO Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice HMO Silver 4200 MD0000201465	Show Clear Choice HMO Silver 4200 SOB	Show Clear Choice HMO Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice HMO Bronze 7500 MD0000201466	Show Clear Choice HMO Bronze 7500 SOB	Show Clear Choice HMO Bronze 7500 SBC

RX: RX0000201251 Vision: VS0000201158
Clear Choice HMO Bronze 9200 MD0000201467	Show Clear Choice HMO Bronze 9200 SOB	Show Clear Choice HMO Bronze 9200 SBC

RX: RX0000201252 Vision: VS0000201158
HMO Silver 5500 MD0000201497	Show HMO Silver 5500 SOB	Show HMO Silver 5500 SBC

RX: RX0000201300 Vision: VS0000201157
HMO Silver 5700 MD0000201499	Show HMO Silver 5700 SOB	Show HMO Silver 5700 SBC

RX: RX0000201256 Vision: VS0000201156
Clear Choice HMO HSA Silver 3500 MD0000201468	Show Clear Choice HMO HSA Silver 3500 SOB	Show Clear Choice HMO HSA Silver 3500 SBC

RX: RX0000201253 Vision: VS0000201159
Clear Choice HMO HSA Silver 4500 MD0000201483	Show Clear Choice HMO HSA Silver 4500 SOB	Show Clear Choice HMO HSA Silver 4500 SBC

RX: RX0000201257 Vision: VS0000201159
Clear Choice HMO HSA Bronze 6300 MD0000201469	Show Clear Choice HMO HSA Bronze 6300 SOB	Show Clear Choice HMO HSA Bronze 6300 SBC

RX: RX0000201258 Vision: VS0000201160
Clear Choice HMO HSA Bronze 7200 MD0000201471	Show Clear Choice HMO HSA Bronze 7200 SOB	Show Clear Choice HMO HSA Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161
HMO HSA Bronze 5500 MD0000201473	Show HMO HSA Bronze 5500 SOB	Show HMO HSA Bronze 5500 SBC

RX: RX0000201259 Vision: VS0000201157
Clear Choice HMO Catastrophic 9200 MD0000201484	Show Clear Choice HMO Catastrophic 9200 SOB	Show Clear Choice HMO Catastrophic 9200 SBC

RX: RX0000201260 Vision: VS0000201158
Clear Choice Maine's Choice Plus HMO Gold 1500 MD0000201502	Show Clear Choice Maine's Choice Plus HMO Gold 1500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 1500 SBC

RX: RX0000201247 Vision: VS0000201176
Clear Choice Maine's Choice Plus HMO Gold 2500 MD0000201503	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SBC

RX: RX0000201249 Vision: VS0000201176
Clear Choice Maine's Choice Plus HMO Silver 3500 MD0000201504	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice Maine's Choice Plus HMO Silver 4200 MD0000201512	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice Maine's Choice Plus HMO Silver 4200 w/ Pedi Dental MD0000201538	Show Clear Choice Maine's Choice Plus HMO Silver 4200 w/ Pedi Dental SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 w/ Pedi Dental SBC

RX: RX0000201279 Vision: VS0000201157
Clear Choice Maine's Choice Plus HMO Bronze 7500 MD0000201537	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SOB	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SBC

RX: RX0000201268 Vision: VS0000201158
Maine's Choice Plus HMO Silver 5500 MD0000201517	Show Maine's Choice Plus HMO Silver 5500 SOB	Show Maine's Choice Plus HMO Silver 5500 SBC

RX: RX0000201300 Vision: VS0000201157
Maine's Choice Plus HMO Silver 5700 MD0000201535	Show Maine's Choice Plus HMO Silver 5700 SOB	Show Maine's Choice Plus HMO Silver 5700 SBC

RX: RX0000201256 Vision: VS0000201156
Clear Choice Maine's Choice Plus HMO HSA Silver 3500 MD0000201506	Show Clear Choice Maine's Choice Plus HMO HSA Silver 3500 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Silver 3500 SBC

RX: RX0000201253 Vision: VS0000201159
Clear Choice Maine's Choice Plus HMO HSA Silver 4500 MD0000201507	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: RX0000201257 Vision: VS0000201159
Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 MD0000201495	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: RX0000201258 Vision: VS0000201160
Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 MD0000201513	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161
Maine's Choice Plus HMO HSA Bronze 5500 MD0000201520	Show Maine's Choice Plus HMO HSA Bronze 5500 SOB	Show Maine's Choice Plus HMO HSA Bronze 5500 SBC

RX: RX0000201259 Vision: VS0000201157

HMO - OFF EXCHANGE without Dental	SOB	SBC
Clear Choice HMO Gold 1500 MD0000201461	Show Clear Choice HMO Gold 1500 SOB	Show Clear Choice HMO Gold 1500 SBC

RX: RX0000201247 Vision: VS0000201176
Clear Choice HMO Gold 2500 MD0000201462	Show Clear Choice HMO Gold 2500 SOB	Show Clear Choice HMO Gold 2500 SBC

RX: RX0000201249 Vision: VS0000201176
Clear Choice HMO Silver 3500 MD0000201464	Show Clear Choice HMO Silver 3500 SOB	Show Clear Choice HMO Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice HMO Silver 4200 MD0000201496	Show Clear Choice HMO Silver 4200 SOB	Show Clear Choice HMO Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice HMO Bronze 7500 MD0000201466	Show Clear Choice HMO Bronze 7500 SOB	Show Clear Choice HMO Bronze 7500 SBC

RX: RX0000201251 Vision: VS0000201158
Clear Choice HMO Bronze 9200 MD0000201467	Show Clear Choice HMO Bronze 9200 SOB	Show Clear Choice HMO Bronze 9200 SBC

RX: RX0000201252 Vision: VS0000201158
HMO Silver 5500 MD0000201498	Show HMO Silver 5500 SOB	Show HMO Silver 5500 SBC

RX: RX0000201300 Vision: VS0000201157
HMO Silver 5700 MD0000201499	Show HMO Silver 5700 SOB	Show HMO Silver 5700 SBC

RX: RX0000201256 Vision: VS0000201156
Clear Choice HMO HSA Silver 3500 MD0000201468	Show Clear Choice HMO HSA Silver 3500 SOB	Show Clear Choice HMO HSA Silver 3500 SBC

RX: RX0000201253 Vision: VS0000201159
Clear Choice HMO HSA Silver 4500 MD0000201483	Show Clear Choice HMO HSA Silver 4500 SOB	Show Clear Choice HMO HSA Silver 4500 SBC

RX: RX0000201257 Vision: VS0000201159
Clear Choice HMO HSA Bronze 6300 MD0000201469	Show Clear Choice HMO HSA Bronze 6300 SOB	Show Clear Choice HMO HSA Bronze 6300 SBC

RX: RX0000201258 Vision: VS0000201160
Clear Choice HMO HSA Bronze 7200 MD0000201471	Show Clear Choice HMO HSA Bronze 7200 SOB	Show Clear Choice HMO HSA Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161
HMO HSA Bronze 5500 MD0000201473	Show HMO HSA Bronze 5500 SOB	Show HMO HSA Bronze 5500 SBC

RX: RX0000201259 Vision: VS0000201157
Clear Choice HMO Catastrophic 9200 MD0000201484	Show Clear Choice HMO Catastrophic 9200 SOB	Show Clear Choice HMO Catastrophic 9200 SBC

RX: RX0000201260 Vision: VS0000201158
Clear Choice Maine's Choice Plus HMO Gold 1500 MD0000201502	Show Clear Choice Maine's Choice Plus HMO Gold 1500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 1500 SBC

RX: RX0000201247 Vision: VS0000201176
Clear Choice Maine's Choice Plus HMO Gold 2500 MD0000201503	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SBC

RX: RX0000201249 Vision: VS0000201176
Clear Choice Maine's Choice Plus HMO Silver 3500 MD0000201505	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice Maine's Choice Plus HMO Silver 4200 MD0000201539	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice Maine's Choice Plus HMO Bronze 7500 MD0000201537	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SOB	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SBC

RX: RX0000201268 Vision: VS0000201158
Maine's Choice Plus HMO Silver 5500 MD0000201518	Show Maine's Choice Plus HMO Silver 5500 SOB	Show Maine's Choice Plus HMO Silver 5500 SBC

RX: RX0000201300 Vision: VS0000201157
Maine's Choice Plus HMO Silver 5700 MD0000201535	Show Maine's Choice Plus HMO Silver 5700 SOB	Show Maine's Choice Plus HMO Silver 5700 SBC

RX: RX0000201256 Vision: VS0000201156
Clear Choice Maine's Choice Plus HMO HSA Silver 3500 MD0000201506	Show Clear Choice Maine's Choice Plus HMO HSA Silver 3500 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Silver 3500 SBC

RX: RX0000201253 Vision: VS0000201159
Clear Choice Maine's Choice Plus HMO HSA Silver 4500 MD0000201507	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: RX0000201257 Vision: VS0000201159
Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 MD0000201495	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: RX0000201258 Vision: VS0000201160
Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 MD0000201513	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161
Maine's Choice Plus HMO HSA Bronze 5500 MD0000201520	Show Maine's Choice Plus HMO HSA Bronze 5500 SOB	Show Maine's Choice Plus HMO HSA Bronze 5500 SBC

RX: RX0000201259 Vision: VS0000201157

HMO - ON EXCHANGE without Dental	SOB	SBC
Clear Choice HMO Gold 1500 MD0000201461	Show Clear Choice HMO Gold 1500 SOB	Show Clear Choice HMO Gold 1500 SBC

RX: RX0000201247 Vision: VS0000201176
Clear Choice HMO Gold 2500 MD0000201462	Show Clear Choice HMO Gold 2500 SOB	Show Clear Choice HMO Gold 2500 SBC

RX: RX0000201249 Vision: VS0000201176
Clear Choice HMO Silver 3500 MD0000201464	Show Clear Choice HMO Silver 3500 SOB	Show Clear Choice HMO Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice HMO Silver 4200 MD0000201496	Show Clear Choice HMO Silver 4200 SOB	Show Clear Choice HMO Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice HMO Bronze 7500 MD0000201466	Show Clear Choice HMO Bronze 7500 SOB	Show Clear Choice HMO Bronze 7500 SBC

RX: RX0000201251 Vision: VS0000201158
Clear Choice HMO Bronze 9200 MD0000201467	Show Clear Choice HMO Bronze 9200 SOB	Show Clear Choice HMO Bronze 9200 SBC

RX: RX0000201252 Vision: VS0000201158
HMO Silver 5500 MD0000201498	Show HMO Silver 5500 SOB	Show HMO Silver 5500 SBC

RX: RX0000201300 Vision: VS0000201157
Clear Choice HMO HSA Bronze 6300 MD0000201469	Show Clear Choice HMO HSA Bronze 6300 SOB	Show Clear Choice HMO HSA Bronze 6300 SBC

RX: RX0000201258 Vision: VS0000201160
Clear Choice HMO HSA Bronze 7200 MD0000201471	Show Clear Choice HMO HSA Bronze 7200 SOB	Show Clear Choice HMO HSA Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161
HMO HSA Bronze 5500 MD0000201473	Show HMO HSA Bronze 5500 SOB	Show HMO HSA Bronze 5500 SBC

RX: RX0000201259 Vision: VS0000201157
Clear Choice HMO Catastrophic 9200 MD0000201484	Show Clear Choice HMO Catastrophic 9200 SOB	Show Clear Choice HMO Catastrophic 9200 SBC

RX: RX0000201260 Vision: VS0000201158
Clear Choice Maine's Choice Plus HMO Gold 2500 MD0000201503	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SBC

RX: RX0000201249 Vision: VS0000201176
Clear Choice Maine's Choice Plus HMO Silver 3500 MD0000201505	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice Maine's Choice Plus HMO Silver 4200 MD0000201539	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice Maine's Choice Plus HMO Bronze 7500 MD0000201537	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SOB	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SBC

RX: RX0000201268 Vision: VS0000201158
Maine's Choice Plus HMO Silver 5500 MD0000201518	Show Maine's Choice Plus HMO Silver 5500 SOB	Show Maine's Choice Plus HMO Silver 5500 SBC

RX: RX0000201300 Vision: VS0000201157
Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 MD0000201495	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: RX0000201258 Vision: VS0000201160
Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 MD0000201513	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161
Maine's Choice Plus HMO HSA Bronze 5500 MD0000201520	Show Maine's Choice Plus HMO HSA Bronze 5500 SOB	Show Maine's Choice Plus HMO HSA Bronze 5500 SBC

RX: RX0000201259 Vision: VS0000201157

HMO - ON EXCHANGE without Dental - AI/AN - Limited	SOB	SBC
Clear Choice HMO Gold 1500 MD0000201461	Show Clear Choice HMO Gold 1500 SOB	Show Clear Choice HMO Gold 1500 SBC

RX: RX0000201247 Vision: VS0000201176
Clear Choice HMO Gold 2500 MD0000201462	Show Clear Choice HMO Gold 2500 SOB	Show Clear Choice HMO Gold 2500 SBC

RX: RX0000201249 Vision: VS0000201176
Clear Choice HMO Silver 3500 MD0000201464	Show Clear Choice HMO Silver 3500 SOB	Show Clear Choice HMO Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice HMO Silver 4200 MD0000201496	Show Clear Choice HMO Silver 4200 SOB	Show Clear Choice HMO Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice HMO Bronze 7500 MD0000201466	Show Clear Choice HMO Bronze 7500 SOB	Show Clear Choice HMO Bronze 7500 SBC

RX: RX0000201251 Vision: VS0000201158
Clear Choice HMO Bronze 9200 MD0000201467	Show Clear Choice HMO Bronze 9200 SOB	Show Clear Choice HMO Bronze 9200 SBC

RX: RX0000201252 Vision: VS0000201158
HMO Silver 5500 MD0000201498	Show HMO Silver 5500 SOB	Show HMO Silver 5500 SBC

RX: RX0000201300 Vision: VS0000201157
Clear Choice HMO Bronze 6300 MD0000201470	Show Clear Choice HMO Bronze 6300 SOB	Show Clear Choice HMO Bronze 6300 SBC

RX: RX0000201258 Vision: VS0000201160
Clear Choice HMO Bronze 7200 MD0000201472	Show Clear Choice HMO Bronze 7200 SOB	Show Clear Choice HMO Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161
HMO Bronze 5500 MD0000201474	Show HMO Bronze 5500 SOB	Show HMO Bronze 5500 SBC

RX: RX0000201259 Vision: VS0000201157
Clear Choice Maine's Choice Plus HMO Gold 2500 MD0000201503	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SOB	Show Clear Choice Maine's Choice Plus HMO Gold 2500 SBC

RX: RX0000201249 Vision: VS0000201176
Clear Choice Maine's Choice Plus HMO Silver 3500 MD0000201505	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice Maine's Choice Plus HMO Silver 4200 MD0000201539	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice Maine's Choice Plus HMO Bronze 7500 MD0000201537	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SOB	Show Clear Choice Maine's Choice Plus HMO Bronze 7500 SBC

RX: RX0000201268 Vision: VS0000201158
Maine's Choice Plus HMO Silver 5500 MD0000201518	Show Maine's Choice Plus HMO Silver 5500 SOB	Show Maine's Choice Plus HMO Silver 5500 SBC

RX: RX0000201300 Vision: VS0000201157
Clear Choice Maine's Choice Plus HMO HSA Bronze 6300 MD0000201495	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: RX0000201258 Vision: VS0000201160
Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 MD0000201519	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 SOB	Show Clear Choice Maine's Choice Plus HMO HSA Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161
Maine's Choice Plus HMO HSA Bronze 5500 MD0000201509	Show Maine's Choice Plus HMO HSA Bronze 5500 SOB	Show Maine's Choice Plus HMO HSA Bronze 5500 SBC

RX: RX0000201259 Vision: VS0000201157

HMO - ON EXCHANGE without Dental - AI/AN - $0 Cost	SOB	SBC
HMO CSR 100 MD0000201511	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
HMO CSR 100 MD0000201511	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
HMO CSR 100 MD0000201511	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
HMO CSR 100 MD0000201511	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
HMO CSR 100 MD0000201511	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
HMO CSR 100 MD0000201511	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
HMO CSR 100 MD0000201511	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
HMO CSR 100 MD0000201511	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
HMO CSR 100 MD0000201511	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
HMO CSR 100 MD0000201511	Show HMO CSR 100 SOB	Show HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
Maine's Choice Plus HMO CSR 100 MD0000201540	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
Maine's Choice Plus HMO CSR 100 MD0000201540	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
Maine's Choice Plus HMO CSR 100 MD0000201540	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
Maine's Choice Plus HMO CSR 100 MD0000201540	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
Maine's Choice Plus HMO CSR 100 MD0000201540	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
Maine's Choice Plus HMO CSR 100 MD0000201540	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
Maine's Choice Plus HMO CSR 100 MD0000201540	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177
Maine's Choice Plus HMO CSR 100 MD0000201540	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177

HMO - ON EXCHANGE without Dental - CSR - 73%	SOB	SBC
Clear Choice HMO Silver 3500 CSR 73 MD0000201475	Show Clear Choice HMO Silver 3500 CSR 73 SOB	Show Clear Choice HMO Silver 3500 CSR 73 SBC

RX: RX0000201261 Vision: VS0000201159
Clear Choice HMO Silver 4200 CSR 73 MD0000201478	Show Clear Choice HMO Silver 4200 CSR 73 SOB	Show Clear Choice HMO Silver 4200 CSR 73 SBC

RX: RX0000201280 Vision: VS0000201178
HMO Silver 5500 CSR 73 MD0000201536	Show HMO Silver 5500 CSR 73 SOB	Show HMO Silver 5500 CSR 73 SBC

RX: RX0000201264 Vision: VS0000201159
Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 73 MD0000201521	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: RX0000201269 Vision: VS0000201167
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 73 MD0000201525	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: RX0000201272 Vision: VS0000201170
Maine's Choice Plus HMO Silver 5500 CSR 73 MD0000201510	Show Maine's Choice Plus HMO Silver 5500 CSR 73 SOB	Show Maine's Choice Plus HMO Silver 5500 CSR 73 SBC

RX: RX0000201278 Vision: VS0000201175

HMO - ON EXCHANGE without Dental - CSR - 87%	SOB	SBC
Clear Choice HMO Silver 3500 CSR 87 MD0000201476	Show Clear Choice HMO Silver 3500 CSR 87 SOB	Show Clear Choice HMO Silver 3500 CSR 87 SBC

RX: RX0000201262 Vision: VS0000201162
Clear Choice HMO Silver 4200 CSR 87 MD0000201479	Show Clear Choice HMO Silver 4200 CSR 87 SOB	Show Clear Choice HMO Silver 4200 CSR 87 SBC

RX: RX0000201265 Vision: VS0000201164
HMO Silver 5500 CSR 87 MD0000201481	Show HMO Silver 5500 CSR 87 SOB	Show HMO Silver 5500 CSR 87 SBC

RX: RX0000201298 Vision: VS0000201164
Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 87 MD0000201522	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: RX0000201270 Vision: VS0000201168
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 87 MD0000201526	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: RX0000201273 Vision: VS0000201168
Maine's Choice Plus HMO Silver 5500 CSR 87 MD0000201533	Show Maine's Choice Plus HMO Silver 5500 CSR 87 SOB	Show Maine's Choice Plus HMO Silver 5500 CSR 87 SBC

RX: RX0000201273 Vision: VS0000201168

HMO - ON EXCHANGE without Dental - CSR - 94%	SOB	SBC
Clear Choice HMO Silver 3500 CSR 94 MD0000201477	Show Clear Choice HMO Silver 3500 CSR 94 SOB	Show Clear Choice HMO Silver 3500 CSR 94 SBC

RX: RX0000201263 Vision: VS0000201163
Clear Choice HMO Silver 4200 CSR 94 MD0000201480	Show Clear Choice HMO Silver 4200 CSR 94 SOB	Show Clear Choice HMO Silver 4200 CSR 94 SBC

RX: RX0000201266 Vision: VS0000201165
HMO Silver 5500 CSR 94 MD0000201482	Show HMO Silver 5500 CSR 94 SOB	Show HMO Silver 5500 CSR 94 SBC

RX: RX0000201267 Vision: VS0000201166
Clear Choice Maine's Choice Plus HMO Silver 3500 CSR 94 MD0000201524	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: RX0000201271 Vision: VS0000201169
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 94 MD0000201527	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: RX0000201274 Vision: VS0000201171
Maine's Choice Plus HMO Silver 5500 CSR 94 MD0000201514	Show Maine's Choice Plus HMO Silver 5500 CSR 94 SOB	Show Maine's Choice Plus HMO Silver 5500 CSR 94 SBC

RX: RX0000201299 Vision: VS0000201171

PPO - OFF EXCHANGE with Dental	SOB	SBC
Clear Choice PPO Access Gold 1500 MD0000201500	Show Clear Choice PPO Access Gold 1500 SOB	Show Clear Choice PPO Access Gold 1500 SBC

RX: RX0000201247 Vision: VS0000201176
Clear Choice PPO Access Gold 2500 MD0000201515	Show Clear Choice PPO Access Gold 2500 SOB	Show Clear Choice PPO Access Gold 2500 SBC

RX: RX0000201249 Vision: VS0000201176
Clear Choice PPO Access Silver 3500 MD0000201516	Show Clear Choice PPO Access Silver 3500 SOB	Show Clear Choice PPO Access Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice PPO Access Silver 4200 MD0000201531	Show Clear Choice PPO Access Silver 4200 SOB	Show Clear Choice PPO Access Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice PPO Access Bronze 9200 MD0000201523	Show Clear Choice PPO Access Bronze 9200 SOB	Show Clear Choice PPO Access Bronze 9200 SBC

RX: RX0000201252 Vision: VS0000201158
PPO Access Silver 5700 MD0000201532	Show PPO Access Silver 5700 SOB	Show PPO Access Silver 5700 SBC

RX: RX0000201256 Vision: VS0000201156
Clear Choice PPO Access HSA Silver 3500 MD0000201485	Show Clear Choice PPO Access HSA Silver 3500 SOB	Show Clear Choice PPO Access HSA Silver 3500 SBC

RX: RX0000201253 Vision: VS0000201159
Clear Choice PPO Access HSA Silver 4500 MD0000201488	Show Clear Choice PPO Access HSA Silver 4500 SOB	Show Clear Choice PPO Access HSA Silver 4500 SBC

RX: RX0000201257 Vision: VS0000201159
Clear Choice PPO Access HSA Bronze 6300 MD0000201489	Show Clear Choice PPO Access HSA Bronze 6300 SOB	Show Clear Choice PPO Access HSA Bronze 6300 SBC

RX: RX0000201258 Vision: VS0000201160
Clear Choice PPO Access HSA Bronze 7200 MD0000201490	Show Clear Choice PPO Access HSA Bronze 7200 SOB	Show Clear Choice PPO Access HSA Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161
PPO Access HSA Bronze 5500 MD0000201508	Show PPO Access HSA Bronze 5500 SOB	Show PPO Access HSA Bronze 5500 SBC

RX: RX0000201259 Vision: VS0000201157

PPO - OFF EXCHANGE without Dental	SOB	SBC
Clear Choice PPO Access Gold 1500 MD0000201500	Show Clear Choice PPO Access Gold 1500 SOB	Show Clear Choice PPO Access Gold 1500 SBC

RX: RX0000201247 Vision: VS0000201176
Clear Choice PPO Access Gold 2500 MD0000201515	Show Clear Choice PPO Access Gold 2500 SOB	Show Clear Choice PPO Access Gold 2500 SBC

RX: RX0000201249 Vision: VS0000201176
Clear Choice PPO Access Silver 3500 MD0000201516	Show Clear Choice PPO Access Silver 3500 SOB	Show Clear Choice PPO Access Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice PPO Access Silver 4200 MD0000201531	Show Clear Choice PPO Access Silver 4200 SOB	Show Clear Choice PPO Access Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice PPO Access Bronze 9200 MD0000201523	Show Clear Choice PPO Access Bronze 9200 SOB	Show Clear Choice PPO Access Bronze 9200 SBC

RX: RX0000201252 Vision: VS0000201158
PPO Access Silver 5700 MD0000201532	Show PPO Access Silver 5700 SOB	Show PPO Access Silver 5700 SBC

RX: RX0000201256 Vision: VS0000201156
Clear Choice PPO Access HSA Silver 3500 MD0000201485	Show Clear Choice PPO Access HSA Silver 3500 SOB	Show Clear Choice PPO Access HSA Silver 3500 SBC

RX: RX0000201253 Vision: VS0000201159
Clear Choice PPO Access HSA Silver 4500 MD0000201488	Show Clear Choice PPO Access HSA Silver 4500 SOB	Show Clear Choice PPO Access HSA Silver 4500 SBC

RX: RX0000201257 Vision: VS0000201159
Clear Choice PPO Access HSA Bronze 6300 MD0000201489	Show Clear Choice PPO Access HSA Bronze 6300 SOB	Show Clear Choice PPO Access HSA Bronze 6300 SBC

RX: RX0000201258 Vision: VS0000201160
Clear Choice PPO Access HSA Bronze 7200 MD0000201490	Show Clear Choice PPO Access HSA Bronze 7200 SOB	Show Clear Choice PPO Access HSA Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161
PPO Access HSA Bronze 5500 MD0000201508	Show PPO Access HSA Bronze 5500 SOB	Show PPO Access HSA Bronze 5500 SBC

RX: RX0000201259 Vision: VS0000201157

POS - OFF EXCHANGE with Dental	SOB	SBC
Clear Choice POS Silver 3500 MD0000201486	Show Clear Choice POS Silver 3500 SOB	Show Clear Choice POS Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice POS Silver 4200 MD0000201491	Show Clear Choice POS Silver 4200 SOB	Show Clear Choice POS Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice POS Bronze 7500 MD0000201487	Show Clear Choice POS Bronze 7500 SOB	Show Clear Choice POS Bronze 7500 SBC

RX: RX0000201251 Vision: VS0000201158
POS Silver 5700 MD0000201501	Show POS Silver 5700 SOB	Show POS Silver 5700 SBC

RX: RX0000201256 Vision: VS0000201156
Clear Choice POS HSA Silver 4500 MD0000201492	Show Clear Choice POS HSA Silver 4500 SOB	Show Clear Choice POS HSA Silver 4500 SBC

RX: RX0000201257 Vision: VS0000201159
Clear Choice POS HSA Bronze 6300 MD0000201494	Show Clear Choice POS HSA Bronze 6300 SOB	Show Clear Choice POS HSA Bronze 6300 SBC

RX: RX0000201258 Vision: VS0000201160
Clear Choice POS HSA Bronze 7200 MD0000201493	Show Clear Choice POS HSA Bronze 7200 SOB	Show Clear Choice POS HSA Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161

POS - OFF EXCHANGE without Dental	SOB	SBC
Clear Choice POS Silver 3500 MD0000201486	Show Clear Choice POS Silver 3500 SOB	Show Clear Choice POS Silver 3500 SBC

RX: RX0000201250 Vision: VS0000201156
Clear Choice POS Silver 4200 MD0000201491	Show Clear Choice POS Silver 4200 SOB	Show Clear Choice POS Silver 4200 SBC

RX: RX0000201255 Vision: VS0000201157
Clear Choice POS Bronze 7500 MD0000201487	Show Clear Choice POS Bronze 7500 SOB	Show Clear Choice POS Bronze 7500 SBC

RX: RX0000201251 Vision: VS0000201158
POS Silver 5700 MD0000201501	Show POS Silver 5700 SOB	Show POS Silver 5700 SBC

RX: RX0000201256 Vision: VS0000201156
Clear Choice POS HSA Silver 4500 MD0000201492	Show Clear Choice POS HSA Silver 4500 SOB	Show Clear Choice POS HSA Silver 4500 SBC

RX: RX0000201257 Vision: VS0000201159
Clear Choice POS HSA Bronze 6300 MD0000201494	Show Clear Choice POS HSA Bronze 6300 SOB	Show Clear Choice POS HSA Bronze 6300 SBC

RX: RX0000201258 Vision: VS0000201160
Clear Choice POS HSA Bronze 7200 MD0000201493	Show Clear Choice POS HSA Bronze 7200 SOB	Show Clear Choice POS HSA Bronze 7200 SBC

RX: RX0000201254 Vision: VS0000201161

HMO - ON EXCHANGE with Dental	SOB	SBC
Clear Choice Maine's Choice Plus HMO Silver 4200 w/ Pedi Dental MD0000201538	Show Clear Choice Maine's Choice Plus HMO Silver 4200 w/ Pedi Dental SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 w/ Pedi Dental SBC

RX: RX0000201279 Vision: VS0000201157

HMO - ON EXCHANGE with Dental - AI/AN - Limited	SOB	SBC
Clear Choice Maine's Choice Plus HMO Silver 4200 w/ Pedi Dental MD0000201538	Show Clear Choice Maine's Choice Plus HMO Silver 4200 w/ Pedi Dental SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 w/ Pedi Dental SBC

RX: RX0000201279 Vision: VS0000201157

HMO - ON EXCHANGE with Dental - AI/AN - $0 Cost	SOB	SBC
Maine's Choice Plus HMO CSR 100 MD0000201534	Show Maine's Choice Plus HMO CSR 100 SOB	Show Maine's Choice Plus HMO CSR 100 SBC

RX: RX0000201248 Vision: VS0000201177

HMO - ON EXCHANGE with Dental - CSR - 73%	SOB	SBC
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 73 - w/ Pedi Dental MD0000201528	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 73 - w/ Pedi Dental SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 73 - w/ Pedi Dental SBC

RX: RX0000201275 Vision: VS0000201172

HMO - ON EXCHANGE with Dental - CSR - 87%	SOB	SBC
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 87- w/ Pedi Dental MD0000201529	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 87- w/ Pedi Dental SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 87- w/ Pedi Dental SBC

RX: RX0000201276 Vision: VS0000201173

HMO - ON EXCHANGE with Dental - CSR - 94%	SOB	SBC
Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 94 - w/ Pedi Dental MD0000201530	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 94 - w/ Pedi Dental SOB	Show Clear Choice Maine's Choice Plus HMO Silver 4200 CSR 94 - w/ Pedi Dental SBC

RX: RX0000201277 Vision: VS0000201174

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