Schedules of Benefits and SBCs: Massachusetts

Individual Market effective 1/1/25

HMO - ON EXCHANGE with Dental	SOB	SBC
Standard Platinum - Flex MD0000201392	Show Standard Platinum - Flex SOB	Show Standard Platinum - Flex SBC

RX: RX0000201220 Vision: VS0000201137
Standard High Gold MD0000201393	Show Standard High Gold SOB	Show Standard High Gold SBC

RX: RX0000201222 Vision: VS0000201140
Standard Silver II MD0000201395	Show Standard Silver II SOB	Show Standard Silver II SBC

RX: RX0000201223 Vision: VS0000201142
Standard High Bronze HSA - Flex MD0000201398	Show Standard High Bronze HSA - Flex SOB	Show Standard High Bronze HSA - Flex SBC

RX: RX0000201228 Vision: VS0000201146
HMO 2000 Value II - Flex MD0000201399	Show HMO 2000 Value II - Flex SOB	Show HMO 2000 Value II - Flex SBC

RX: RX0000201229 Vision: VS0000201147
HMO 3500 - Flex MD0000201401	Show HMO 3500 - Flex SOB	Show HMO 3500 - Flex SBC

RX: RX0000201231 Vision: VS0000201149

HMO - OFF EXCHANGE with Dental	SOB	SBC
Standard Platinum - Flex MD0000201392	Show Standard Platinum - Flex SOB	Show Standard Platinum - Flex SBC

RX: RX0000201220 Vision: VS0000201137
Standard High Gold MD0000201393	Show Standard High Gold SOB	Show Standard High Gold SBC

RX: RX0000201222 Vision: VS0000201140
Standard Silver MD0000201394	Show Standard Silver SOB	Show Standard Silver SBC

RX: RX0000201223 Vision: VS0000201142
Standard Low Silver HSA - Flex MD0000201404	Show Standard Low Silver HSA - Flex SOB	Show Standard Low Silver HSA - Flex SBC

RX: RX0000201227 Vision: VS0000201145
Standard High Bronze HSA - Flex MD0000201398	Show Standard High Bronze HSA - Flex SOB	Show Standard High Bronze HSA - Flex SBC

RX: RX0000201228 Vision: VS0000201146
HMO 2000 Value II - Flex MD0000201399	Show HMO 2000 Value II - Flex SOB	Show HMO 2000 Value II - Flex SBC

RX: RX0000201229 Vision: VS0000201147
HMO 3500 - Flex MD0000201401	Show HMO 3500 - Flex SOB	Show HMO 3500 - Flex SBC

RX: RX0000201231 Vision: VS0000201149
HMO 20 - Flex MD0000201427	Show HMO 20 - Flex SOB	Show HMO 20 - Flex SBC

RX: RX0000201233 Vision: VS0000201150
HMO 500 - Flex MD0000201446	Show HMO 500 - Flex SOB	Show HMO 500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
HMO 1000 - Flex MD0000201458	Show HMO 1000 - Flex SOB	Show HMO 1000 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
HMO 1500 - Flex MD0000201431	Show HMO 1500 - Flex SOB	Show HMO 1500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
HMO 1500 Value - Flex MD0000201432	Show HMO 1500 Value - Flex SOB	Show HMO 1500 Value - Flex SBC

RX: RX0000201235 Vision: VS0000201152
HMO 2000 - Flex MD0000201433	Show HMO 2000 - Flex SOB	Show HMO 2000 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
HMO 2000 Value - Flex MD0000201436	Show HMO 2000 Value - Flex SOB	Show HMO 2000 Value - Flex SBC

RX: RX0000201236 Vision: VS0000201153
HMO 2500 - Flex MD0000201434	Show HMO 2500 - Flex SOB	Show HMO 2500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
HMO 3000 - Flex MD0000201437	Show HMO 3000 - Flex SOB	Show HMO 3000 - Flex SBC

RX: RX0000201237 Vision: VS0000201153
HMO 4000 - Flex MD0000201445	Show HMO 4000 - Flex SOB	Show HMO 4000 - Flex SBC

RX: RX0000201237 Vision: VS0000201153
HMO 5000 - Flex MD0000201438	Show HMO 5000 - Flex SOB	Show HMO 5000 - Flex SBC

RX: RX0000201237 Vision: VS0000201153
HMO 6000 Value - Flex MD0000201459	Show HMO 6000 Value - Flex SOB	Show HMO 6000 Value - Flex SBC

RX: RX0000201238 Vision: VS0000201153
HMO HSA 2000 - Flex MD0000201414	Show HMO HSA 2000 - Flex SOB	Show HMO HSA 2000 - Flex SBC

RX: RX0000201239 Vision: VS0000201154
HMO HSA 2500 - Flex MD0000201447	Show HMO HSA 2500 - Flex SOB	Show HMO HSA 2500 - Flex SBC

RX: RX0000201240 Vision: VS0000201154
HMO HSA 3000 - Flex MD0000201428	Show HMO HSA 3000 - Flex SOB	Show HMO HSA 3000 - Flex SBC

RX: RX0000201241 Vision: VS0000201154
HMO HSA 3400 - Flex MD0000201429	Show HMO HSA 3400 - Flex SOB	Show HMO HSA 3400 - Flex SBC

RX: RX0000201242 Vision: VS0000201154
HMO HSA 4000 - Flex MD0000201430	Show HMO HSA 4000 - Flex SOB	Show HMO HSA 4000 - Flex SBC

RX: RX0000201243 Vision: VS0000201154
Focus HMO 1000 MD0000201448	Show Focus HMO 1000 SOB	Show Focus HMO 1000 SBC

RX: RX0000201234 Vision: VS0000201151
Focus HMO 1500 MD0000201449	Show Focus HMO 1500 SOB	Show Focus HMO 1500 SBC

RX: RX0000201234 Vision: VS0000201151
Focus HMO 2000 MD0000201450	Show Focus HMO 2000 SOB	Show Focus HMO 2000 SBC

RX: RX0000201234 Vision: VS0000201151
Focus HMO 2500 MD0000201435	Show Focus HMO 2500 SOB	Show Focus HMO 2500 SBC

RX: RX0000201234 Vision: VS0000201151
Focus HMO 3000 MD0000201451	Show Focus HMO 3000 SOB	Show Focus HMO 3000 SBC

RX: RX0000201237 Vision: VS0000201153
Focus HMO HSA 3400 MD0000201415	Show Focus HMO HSA 3400 SOB	Show Focus HMO HSA 3400 SBC

RX: RX0000201244 Vision: VS0000201151

HMO - ON EXCHANGE with Dental - AI/AN - Limited	SOB	SBC
Standard Platinum - Flex MD0000201392	Show Standard Platinum - Flex SOB	Show Standard Platinum - Flex SBC

RX: RX0000201220 Vision: VS0000201137
Standard High Gold MD0000201393	Show Standard High Gold SOB	Show Standard High Gold SBC

RX: RX0000201222 Vision: VS0000201140
Standard Silver II MD0000201395	Show Standard Silver II SOB	Show Standard Silver II SBC

RX: RX0000201223 Vision: VS0000201142
Standard High Bronze - Flex MD0000201402	Show Standard High Bronze - Flex SOB	Show Standard High Bronze - Flex SBC

RX: RX0000201228 Vision: VS0000201146
HMO 2000 Value II - Flex MD0000201399	Show HMO 2000 Value II - Flex SOB	Show HMO 2000 Value II - Flex SBC

RX: RX0000201229 Vision: VS0000201147
HMO 3500 - Flex MD0000201401	Show HMO 3500 - Flex SOB	Show HMO 3500 - Flex SBC

RX: RX0000201231 Vision: VS0000201149

HMO - ON EXCHANGE with Dental - AI/AN - $0	SOB	SBC
HMO MD0000201412	Show HMO SOB	Show HMO SBC

RX: RX0000201221 Vision: VS0000201138
HMO MD0000201412	Show HMO SOB	Show HMO SBC

RX: RX0000201221 Vision: VS0000201138
HMO MD0000201412	Show HMO SOB	Show HMO SBC

RX: RX0000201221 Vision: VS0000201138
HMO MD0000201412	Show HMO SOB	Show HMO SBC

RX: RX0000201221 Vision: VS0000201138
HMO MD0000201412	Show HMO SOB	Show HMO SBC

RX: RX0000201221 Vision: VS0000201138
HMO MD0000201412	Show HMO SOB	Show HMO SBC

RX: RX0000201221 Vision: VS0000201138

HMO - ON EXCHANGE with Dental - CSR - 94%	SOB	SBC
Standard ConnectorCare 1 MD0000201413	Show Standard ConnectorCare 1 SOB	Show Standard ConnectorCare 1 SBC

RX: RX0000201224 Vision: VS0000201141

HMO - ON EXCHANGE with Dental - CSR - 87%	SOB	SBC
Standard ConnectorCare 2 MD0000201396	Show Standard ConnectorCare 2 SOB	Show Standard ConnectorCare 2 SBC

RX: RX0000201225 Vision: VS0000201143

HMO - ON EXCHANGE with Dental - CSR - 73%	SOB	SBC
Standard ConnectorCare 3 MD0000201397	Show Standard ConnectorCare 3 SOB	Show Standard ConnectorCare 3 SBC

RX: RX0000201226 Vision: VS0000201144

PPO - OFF EXCHANGE with Dental	SOB	SBC
PPO HSA 2000 - Flex MD0000201400	Show PPO HSA 2000 - Flex SOB	Show PPO HSA 2000 - Flex SBC

RX: RX0000201230 Vision: VS0000201148
PPO 20 - Flex MD0000201439	Show PPO 20 - Flex SOB	Show PPO 20 - Flex SBC

RX: RX0000201233 Vision: VS0000201150
PPO 500 - Flex MD0000201440	Show PPO 500 - Flex SOB	Show PPO 500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
PPO 1000 - Flex MD0000201441	Show PPO 1000 - Flex SOB	Show PPO 1000 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
PPO 1500 - Flex MD0000201442	Show PPO 1500 - Flex SOB	Show PPO 1500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
PPO 1500 Value - Flex MD0000201452	Show PPO 1500 Value - Flex SOB	Show PPO 1500 Value - Flex SBC

RX: RX0000201237 Vision: VS0000201153
PPO 2000 - Flex MD0000201443	Show PPO 2000 - Flex SOB	Show PPO 2000 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
PPO 2000 Value - Flex MD0000201444	Show PPO 2000 Value - Flex SOB	Show PPO 2000 Value - Flex SBC

RX: RX0000201237 Vision: VS0000201153
PPO 2500 - Flex MD0000201453	Show PPO 2500 - Flex SOB	Show PPO 2500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
PPO 3000 - Flex MD0000201454	Show PPO 3000 - Flex SOB	Show PPO 3000 - Flex SBC

RX: RX0000201237 Vision: VS0000201153
PPO 4000 - Flex MD0000201455	Show PPO 4000 - Flex SOB	Show PPO 4000 - Flex SBC

RX: RX0000201237 Vision: VS0000201153
PPO HSA 3000 - Flex MD0000201456	Show PPO HSA 3000 - Flex SOB	Show PPO HSA 3000 - Flex SBC

RX: RX0000201241 Vision: VS0000201154
PPO HSA 3400 - Flex MD0000201460	Show PPO HSA 3400 - Flex SOB	Show PPO HSA 3400 - Flex SBC

RX: RX0000201242 Vision: VS0000201154
PPO HSA 5000 - Flex MD0000201457	Show PPO HSA 5000 - Flex SOB	Show PPO HSA 5000 - Flex SBC

RX: RX0000201245 Vision: VS0000201154

HMO - OFF EXCHANGE without Dental	SOB	SBC
HMO 20 - Flex MD0000201427	Show HMO 20 - Flex SOB	Show HMO 20 - Flex SBC

RX: RX0000201233 Vision: VS0000201150
HMO 500 - Flex MD0000201446	Show HMO 500 - Flex SOB	Show HMO 500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
HMO 1000 - Flex MD0000201458	Show HMO 1000 - Flex SOB	Show HMO 1000 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
HMO 1500 - Flex MD0000201431	Show HMO 1500 - Flex SOB	Show HMO 1500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
HMO 1500 Value - Flex MD0000201432	Show HMO 1500 Value - Flex SOB	Show HMO 1500 Value - Flex SBC

RX: RX0000201235 Vision: VS0000201152
HMO 2000 - Flex MD0000201433	Show HMO 2000 - Flex SOB	Show HMO 2000 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
HMO 2000 Value - Flex MD0000201436	Show HMO 2000 Value - Flex SOB	Show HMO 2000 Value - Flex SBC

RX: RX0000201236 Vision: VS0000201153
HMO 2500 - Flex MD0000201434	Show HMO 2500 - Flex SOB	Show HMO 2500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
HMO 3000 - Flex MD0000201437	Show HMO 3000 - Flex SOB	Show HMO 3000 - Flex SBC

RX: RX0000201237 Vision: VS0000201153
HMO 4000 - Flex MD0000201445	Show HMO 4000 - Flex SOB	Show HMO 4000 - Flex SBC

RX: RX0000201237 Vision: VS0000201153
HMO 5000 - Flex MD0000201438	Show HMO 5000 - Flex SOB	Show HMO 5000 - Flex SBC

RX: RX0000201237 Vision: VS0000201153
HMO 6000 Value - Flex MD0000201459	Show HMO 6000 Value - Flex SOB	Show HMO 6000 Value - Flex SBC

RX: RX0000201238 Vision: VS0000201153
HMO HSA 2000 - Flex MD0000201414	Show HMO HSA 2000 - Flex SOB	Show HMO HSA 2000 - Flex SBC

RX: RX0000201239 Vision: VS0000201154
HMO HSA 2500 - Flex MD0000201447	Show HMO HSA 2500 - Flex SOB	Show HMO HSA 2500 - Flex SBC

RX: RX0000201240 Vision: VS0000201154
HMO HSA 3000 - Flex MD0000201428	Show HMO HSA 3000 - Flex SOB	Show HMO HSA 3000 - Flex SBC

RX: RX0000201241 Vision: VS0000201154
HMO HSA 3400 - Flex MD0000201429	Show HMO HSA 3400 - Flex SOB	Show HMO HSA 3400 - Flex SBC

RX: RX0000201242 Vision: VS0000201154
HMO HSA 4000 - Flex MD0000201430	Show HMO HSA 4000 - Flex SOB	Show HMO HSA 4000 - Flex SBC

RX: RX0000201243 Vision: VS0000201154
Focus HMO 1000 MD0000201448	Show Focus HMO 1000 SOB	Show Focus HMO 1000 SBC

RX: RX0000201234 Vision: VS0000201151
Focus HMO 1500 MD0000201449	Show Focus HMO 1500 SOB	Show Focus HMO 1500 SBC

RX: RX0000201234 Vision: VS0000201151
Focus HMO 2000 MD0000201450	Show Focus HMO 2000 SOB	Show Focus HMO 2000 SBC

RX: RX0000201234 Vision: VS0000201151
Focus HMO 2500 MD0000201435	Show Focus HMO 2500 SOB	Show Focus HMO 2500 SBC

RX: RX0000201234 Vision: VS0000201151
Focus HMO 3000 MD0000201451	Show Focus HMO 3000 SOB	Show Focus HMO 3000 SBC

RX: RX0000201237 Vision: VS0000201153
Focus HMO HSA 3400 MD0000201415	Show Focus HMO HSA 3400 SOB	Show Focus HMO HSA 3400 SBC

RX: RX0000201244 Vision: VS0000201151

PPO - OFF EXCHANGE without Dental	SOB	SBC
PPO 20 - Flex MD0000201439	Show PPO 20 - Flex SOB	Show PPO 20 - Flex SBC

RX: RX0000201233 Vision: VS0000201150
PPO 500 - Flex MD0000201440	Show PPO 500 - Flex SOB	Show PPO 500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
PPO 1000 - Flex MD0000201441	Show PPO 1000 - Flex SOB	Show PPO 1000 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
PPO 1500 - Flex MD0000201442	Show PPO 1500 - Flex SOB	Show PPO 1500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
PPO 1500 Value - Flex MD0000201452	Show PPO 1500 Value - Flex SOB	Show PPO 1500 Value - Flex SBC

RX: RX0000201237 Vision: VS0000201153
PPO 2000 - Flex MD0000201443	Show PPO 2000 - Flex SOB	Show PPO 2000 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
PPO 2000 Value - Flex MD0000201444	Show PPO 2000 Value - Flex SOB	Show PPO 2000 Value - Flex SBC

RX: RX0000201237 Vision: VS0000201153
PPO 2500 - Flex MD0000201453	Show PPO 2500 - Flex SOB	Show PPO 2500 - Flex SBC

RX: RX0000201234 Vision: VS0000201151
PPO 3000 - Flex MD0000201454	Show PPO 3000 - Flex SOB	Show PPO 3000 - Flex SBC

RX: RX0000201237 Vision: VS0000201153
PPO 4000 - Flex MD0000201455	Show PPO 4000 - Flex SOB	Show PPO 4000 - Flex SBC

RX: RX0000201237 Vision: VS0000201153
PPO HSA 3000 - Flex MD0000201456	Show PPO HSA 3000 - Flex SOB	Show PPO HSA 3000 - Flex SBC

RX: RX0000201241 Vision: VS0000201154
PPO HSA 3400 - Flex MD0000201460	Show PPO HSA 3400 - Flex SOB	Show PPO HSA 3400 - Flex SBC

RX: RX0000201242 Vision: VS0000201154
PPO HSA 5000 - Flex MD0000201457	Show PPO HSA 5000 - Flex SOB	Show PPO HSA 5000 - Flex SBC

RX: RX0000201245 Vision: VS0000201154

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Individual Market effective 1/1/25