Schedules of Benefits and SBCs: Massachusetts

Individual Market effective 1/1/24

HMO - ON EXCHANGE with Dental	SOB	SBC
Standard Platinum - Flex MD0000201122	Show Standard Platinum - Flex SOB	Show Standard Platinum - Flex SBC

RX: RX0000201064 Vision: VS0000201035
Standard High Gold MD0000201116	Show Standard High Gold SOB	Show Standard High Gold SBC

RX: RX0000201066 Vision: VS0000201037
Standard High Bronze HSA - Flex MD0000201126	Show Standard High Bronze HSA - Flex SOB	Show Standard High Bronze HSA - Flex SBC

RX: RX0000201069 Vision: VS0000201040
HMO 2000 Low - Flex MD0000201123	Show HMO 2000 Low - Flex SOB	Show HMO 2000 Low - Flex SBC

RX: RX0000201070 Vision: VS0000201041
HMO 3500 - Flex MD0000201124	Show HMO 3500 - Flex SOB	Show HMO 3500 - Flex SBC

RX: RX0000201072 Vision: VS0000201043
Standard Silver II MD0000201164	Show Standard Silver II SOB	Show Standard Silver II SBC

RX: RX0000201067 Vision: VS0000201038

HMO - OFF EXCHANGE with Dental	SOB	SBC
Standard Platinum - Flex MD0000201122	Show Standard Platinum - Flex SOB	Show Standard Platinum - Flex SBC

RX: RX0000201064 Vision: VS0000201035
Standard High Gold MD0000201116	Show Standard High Gold SOB	Show Standard High Gold SBC

RX: RX0000201066 Vision: VS0000201037
Standard Silver MD0000201117	Show Standard Silver SOB	Show Standard Silver SBC

RX: RX0000201067 Vision: VS0000201038
Standard High Bronze HSA - Flex MD0000201126	Show Standard High Bronze HSA - Flex SOB	Show Standard High Bronze HSA - Flex SBC

RX: RX0000201069 Vision: VS0000201040
HMO 2000 Low - Flex MD0000201123	Show HMO 2000 Low - Flex SOB	Show HMO 2000 Low - Flex SBC

RX: RX0000201070 Vision: VS0000201041
HMO 3500 - Flex MD0000201124	Show HMO 3500 - Flex SOB	Show HMO 3500 - Flex SBC

RX: RX0000201072 Vision: VS0000201043
Standard Low Silver HSA - Flex MD0000201125	Show Standard Low Silver HSA - Flex SOB	Show Standard Low Silver HSA - Flex SBC

RX: RX0000201068 Vision: VS0000201039
HMO 20 - Flex MD0000201128	Show HMO 20 - Flex SOB	Show HMO 20 - Flex SBC

RX: RX0000201077 Vision: VS0000201048
HMO 500 - Flex MD0000201129	Show HMO 500 - Flex SOB	Show HMO 500 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 1000 - Flex MD0000201130	Show HMO 1000 - Flex SOB	Show HMO 1000 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 1500 - Flex MD0000201131	Show HMO 1500 - Flex SOB	Show HMO 1500 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 2000 - Flex MD0000201132	Show HMO 2000 - Flex SOB	Show HMO 2000 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 2500 - Flex MD0000201133	Show HMO 2500 - Flex SOB	Show HMO 2500 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 1500 with Coinsurance - Flex MD0000201134	Show HMO 1500 with Coinsurance - Flex SOB	Show HMO 1500 with Coinsurance - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 2000 with Coinsurance - Flex MD0000201135	Show HMO 2000 with Coinsurance - Flex SOB	Show HMO 2000 with Coinsurance - Flex SBC

RX: RX0000201090 Vision: VS0000201054
HMO 2000 Value - Flex MD0000201136	Show HMO 2000 Value - Flex SOB	Show HMO 2000 Value - Flex SBC

RX: RX0000201079 Vision: VS0000201050
HMO 3000 - Flex MD0000201137	Show HMO 3000 - Flex SOB	Show HMO 3000 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
HMO 4000 - Flex MD0000201138	Show HMO 4000 - Flex SOB	Show HMO 4000 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
HMO 5000 - Flex MD0000201139	Show HMO 5000 - Flex SOB	Show HMO 5000 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
HMO 6000 Value - Flex MD0000201140	Show HMO 6000 Value - Flex SOB	Show HMO 6000 Value - Flex SBC

RX: RX0000201081 Vision: VS0000201050
HMO HSA 2000 - Flex MD0000201141	Show HMO HSA 2000 - Flex SOB	Show HMO HSA 2000 - Flex SBC

RX: RX0000201082 Vision: VS0000201051
HMO HSA 2500 - Flex MD0000201142	Show HMO HSA 2500 - Flex SOB	Show HMO HSA 2500 - Flex SBC

RX: RX0000201083 Vision: VS0000201051
HMO HSA 3000 - Flex MD0000201143	Show HMO HSA 3000 - Flex SOB	Show HMO HSA 3000 - Flex SBC

RX: RX0000201084 Vision: VS0000201051
HMO HSA 3400 - Flex MD0000201144	Show HMO HSA 3400 - Flex SOB	Show HMO HSA 3400 - Flex SBC

RX: RX0000201085 Vision: VS0000201051
HMO HSA 4000 - Flex MD0000201145	Show HMO HSA 4000 - Flex SOB	Show HMO HSA 4000 - Flex SBC

RX: RX0000201086 Vision: VS0000201051
Focus HMO 1000 MD0000201146	Show Focus HMO 1000 SOB	Show Focus HMO 1000 SBC

RX: RX0000201078 Vision: VS0000201049
Focus HMO 1500 MD0000201147	Show Focus HMO 1500 SOB	Show Focus HMO 1500 SBC

RX: RX0000201078 Vision: VS0000201049
Focus HMO 2000 MD0000201148	Show Focus HMO 2000 SOB	Show Focus HMO 2000 SBC

RX: RX0000201078 Vision: VS0000201049
Focus HMO 2500 MD0000201149	Show Focus HMO 2500 SOB	Show Focus HMO 2500 SBC

RX: RX0000201088 Vision: VS0000201053
Focus HMO 3000 MD0000201150	Show Focus HMO 3000 SOB	Show Focus HMO 3000 SBC

RX: RX0000201080 Vision: VS0000201050
Focus HMO HSA 3400 MD0000201151	Show Focus HMO HSA 3400 SOB	Show Focus HMO HSA 3400 SBC

RX: RX0000201089 Vision: VS0000201049

HMO - ON EXCHANGE with Dental - AI/AN - Limited	SOB	SBC
Standard Platinum - Flex MD0000201122	Show Standard Platinum - Flex SOB	Show Standard Platinum - Flex SBC

RX: RX0000201064 Vision: VS0000201035
Standard High Gold MD0000201116	Show Standard High Gold SOB	Show Standard High Gold SBC

RX: RX0000201066 Vision: VS0000201037
Standard High Bronze HSA - Flex MD0000201126	Show Standard High Bronze HSA - Flex SOB	Show Standard High Bronze HSA - Flex SBC

RX: RX0000201069 Vision: VS0000201040
HMO 2000 Low - Flex MD0000201123	Show HMO 2000 Low - Flex SOB	Show HMO 2000 Low - Flex SBC

RX: RX0000201070 Vision: VS0000201041
HMO 3500 - Flex MD0000201124	Show HMO 3500 - Flex SOB	Show HMO 3500 - Flex SBC

RX: RX0000201072 Vision: VS0000201043
Standard Silver II MD0000201164	Show Standard Silver II SOB	Show Standard Silver II SBC

RX: RX0000201067 Vision: VS0000201038

HMO - ON EXCHANGE with Dental - AI/AN - $0 Cost	SOB	SBC
HMO MD0000201115	Show HMO SOB	Show HMO SBC

RX: RX0000201065 Vision: VS0000201036
HMO MD0000201115	Show HMO SOB	Show HMO SBC

RX: RX0000201065 Vision: VS0000201036
HMO MD0000201115	Show HMO SOB	Show HMO SBC

RX: RX0000201065 Vision: VS0000201036
HMO MD0000201115	Show HMO SOB	Show HMO SBC

RX: RX0000201065 Vision: VS0000201036
HMO MD0000201115	Show HMO SOB	Show HMO SBC

RX: RX0000201065 Vision: VS0000201036
HMO MD0000201115	Show HMO SOB	Show HMO SBC

RX: RX0000201065 Vision: VS0000201036

HMO - ON EXCHANGE with Dental - CSR - 94%	SOB	SBC
Standard ConnectorCare 1 MD0000201118	Show Standard ConnectorCare 1 SOB	Show Standard ConnectorCare 1 SBC

RX: RX0000201073 Vision: VS0000201044

HMO - ON EXCHANGE with Dental - CSR - 87%	SOB	SBC
Standard ConnectorCare 2 MD0000201119	Show Standard ConnectorCare 2 SOB	Show Standard ConnectorCare 2 SBC

RX: RX0000201074 Vision: VS0000201045

HMO - ON EXCHANGE with Dental - CSR - 73%	SOB	SBC
Standard ConnectorCare 3 MD0000201120	Show Standard ConnectorCare 3 SOB	Show Standard ConnectorCare 3 SBC

RX: RX0000201075 Vision: VS0000201046

PPO - OFF EXCHANGE with Dental	SOB	SBC
PPO HSA 2000 - Flex MD0000201127	Show PPO HSA 2000 - Flex SOB	Show PPO HSA 2000 - Flex SBC

RX: RX0000201071 Vision: VS0000201042
PPO 20 - Flex MD0000201152	Show PPO 20 - Flex SOB	Show PPO 20 - Flex SBC

RX: RX0000201077 Vision: VS0000201052
PPO 500 - Flex MD0000201153	Show PPO 500 - Flex SOB	Show PPO 500 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
PPO 1000 - Flex MD0000201154	Show PPO 1000 - Flex SOB	Show PPO 1000 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
PPO 1500 - Flex MD0000201155	Show PPO 1500 - Flex SOB	Show PPO 1500 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
PPO 2000 - Flex MD0000201156	Show PPO 2000 - Flex SOB	Show PPO 2000 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
PPO 2500 - Flex MD0000201157	Show PPO 2500 - Flex SOB	Show PPO 2500 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
PPO 2000 Value - Flex MD0000201158	Show PPO 2000 Value - Flex SOB	Show PPO 2000 Value - Flex SBC

RX: RX0000201080 Vision: VS0000201050
PPO 3000 - Flex MD0000201159	Show PPO 3000 - Flex SOB	Show PPO 3000 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
PPO 4000 - Flex MD0000201160	Show PPO 4000 - Flex SOB	Show PPO 4000 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
PPO HSA 3000 - Flex MD0000201161	Show PPO HSA 3000 - Flex SOB	Show PPO HSA 3000 - Flex SBC

RX: RX0000201084 Vision: VS0000201051
PPO HSA 3400 - Flex MD0000201162	Show PPO HSA 3400 - Flex SOB	Show PPO HSA 3400 - Flex SBC

RX: RX0000201085 Vision: VS0000201051
PPO HSA 5000 - Flex MD0000201163	Show PPO HSA 5000 - Flex SOB	Show PPO HSA 5000 - Flex SBC

RX: RX0000201087 Vision: VS0000201051

HMO - OFF EXCHANGE without Dental	SOB	SBC
HMO 20 - Flex MD0000201128	Show HMO 20 - Flex SOB	Show HMO 20 - Flex SBC

RX: RX0000201077 Vision: VS0000201048
HMO 500 - Flex MD0000201129	Show HMO 500 - Flex SOB	Show HMO 500 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 1000 - Flex MD0000201130	Show HMO 1000 - Flex SOB	Show HMO 1000 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 1500 - Flex MD0000201131	Show HMO 1500 - Flex SOB	Show HMO 1500 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 2000 - Flex MD0000201132	Show HMO 2000 - Flex SOB	Show HMO 2000 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 2500 - Flex MD0000201133	Show HMO 2500 - Flex SOB	Show HMO 2500 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 1500 with Coinsurance - Flex MD0000201134	Show HMO 1500 with Coinsurance - Flex SOB	Show HMO 1500 with Coinsurance - Flex SBC

RX: RX0000201078 Vision: VS0000201049
HMO 2000 with Coinsurance - Flex MD0000201135	Show HMO 2000 with Coinsurance - Flex SOB	Show HMO 2000 with Coinsurance - Flex SBC

RX: RX0000201090 Vision: VS0000201054
HMO 2000 Value - Flex MD0000201136	Show HMO 2000 Value - Flex SOB	Show HMO 2000 Value - Flex SBC

RX: RX0000201079 Vision: VS0000201050
HMO 3000 - Flex MD0000201137	Show HMO 3000 - Flex SOB	Show HMO 3000 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
HMO 4000 - Flex MD0000201138	Show HMO 4000 - Flex SOB	Show HMO 4000 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
HMO 5000 - Flex MD0000201139	Show HMO 5000 - Flex SOB	Show HMO 5000 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
HMO 6000 Value - Flex MD0000201140	Show HMO 6000 Value - Flex SOB	Show HMO 6000 Value - Flex SBC

RX: RX0000201081 Vision: VS0000201050
HMO HSA 2000 - Flex MD0000201141	Show HMO HSA 2000 - Flex SOB	Show HMO HSA 2000 - Flex SBC

RX: RX0000201082 Vision: VS0000201051
HMO HSA 2500 - Flex MD0000201142	Show HMO HSA 2500 - Flex SOB	Show HMO HSA 2500 - Flex SBC

RX: RX0000201083 Vision: VS0000201051
HMO HSA 3000 - Flex MD0000201143	Show HMO HSA 3000 - Flex SOB	Show HMO HSA 3000 - Flex SBC

RX: RX0000201084 Vision: VS0000201051
HMO HSA 3400 - Flex MD0000201144	Show HMO HSA 3400 - Flex SOB	Show HMO HSA 3400 - Flex SBC

RX: RX0000201085 Vision: VS0000201051
HMO HSA 4000 - Flex MD0000201145	Show HMO HSA 4000 - Flex SOB	Show HMO HSA 4000 - Flex SBC

RX: RX0000201086 Vision: VS0000201051
Focus HMO 1000 MD0000201146	Show Focus HMO 1000 SOB	Show Focus HMO 1000 SBC

RX: RX0000201078 Vision: VS0000201049
Focus HMO 1500 MD0000201147	Show Focus HMO 1500 SOB	Show Focus HMO 1500 SBC

RX: RX0000201078 Vision: VS0000201049
Focus HMO 2000 MD0000201148	Show Focus HMO 2000 SOB	Show Focus HMO 2000 SBC

RX: RX0000201078 Vision: VS0000201049
Focus HMO 2500 MD0000201149	Show Focus HMO 2500 SOB	Show Focus HMO 2500 SBC

RX: RX0000201088 Vision: VS0000201053
Focus HMO 3000 MD0000201150	Show Focus HMO 3000 SOB	Show Focus HMO 3000 SBC

RX: RX0000201080 Vision: VS0000201050
Focus HMO HSA 3400 MD0000201151	Show Focus HMO HSA 3400 SOB	Show Focus HMO HSA 3400 SBC

RX: RX0000201089 Vision: VS0000201049

PPO - OFF EXCHANGE without Dental	SOB	SBC
PPO 20 - Flex MD0000201152	Show PPO 20 - Flex SOB	Show PPO 20 - Flex SBC

RX: RX0000201077 Vision: VS0000201052
PPO 500 - Flex MD0000201153	Show PPO 500 - Flex SOB	Show PPO 500 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
PPO 1000 - Flex MD0000201154	Show PPO 1000 - Flex SOB	Show PPO 1000 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
PPO 1500 - Flex MD0000201155	Show PPO 1500 - Flex SOB	Show PPO 1500 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
PPO 2000 - Flex MD0000201156	Show PPO 2000 - Flex SOB	Show PPO 2000 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
PPO 2500 - Flex MD0000201157	Show PPO 2500 - Flex SOB	Show PPO 2500 - Flex SBC

RX: RX0000201078 Vision: VS0000201049
PPO 2000 Value - Flex MD0000201158	Show PPO 2000 Value - Flex SOB	Show PPO 2000 Value - Flex SBC

RX: RX0000201080 Vision: VS0000201050
PPO 3000 - Flex MD0000201159	Show PPO 3000 - Flex SOB	Show PPO 3000 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
PPO 4000 - Flex MD0000201160	Show PPO 4000 - Flex SOB	Show PPO 4000 - Flex SBC

RX: RX0000201080 Vision: VS0000201050
PPO HSA 3000 - Flex MD0000201161	Show PPO HSA 3000 - Flex SOB	Show PPO HSA 3000 - Flex SBC

RX: RX0000201084 Vision: VS0000201051
PPO HSA 3400 - Flex MD0000201162	Show PPO HSA 3400 - Flex SOB	Show PPO HSA 3400 - Flex SBC

RX: RX0000201085 Vision: VS0000201051
PPO HSA 5000 - Flex MD0000201163	Show PPO HSA 5000 - Flex SOB	Show PPO HSA 5000 - Flex SBC

RX: RX0000201087 Vision: VS0000201051

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