Schedules of Benefits and SBCs: New Hampshire

Individual Market effective 1/1/24

HMO - OFF EXCHANGE with Dental	SOB	SBC
NH Local Choice HMO Gold MD0000201040	Show NH Local Choice HMO Gold SOB	Show NH Local Choice HMO Gold SBC

RX: RX0000201008 Vision: VS0000201024
NH Local Choice HMO Gold 1400 MD0000201034	Show NH Local Choice HMO Gold 1400 SOB	Show NH Local Choice HMO Gold 1400 SBC

RX: RX0000201010 Vision: VS0000201003
NH Local Choice HMO Silver 2500 MD0000201052	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000201011 Vision: VS0000201004
NH Local Choice HMO Silver 3500 MD0000201056	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000201012 Vision: VS0000201005
NH Local Choice HMO Silver 4000 MD0000201053	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000201014 Vision: VS0000201006
NH Local Choice HMO Silver 5000 MD0000201054	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000201015 Vision: VS0000201005
NH Local Choice HMO Bronze 6500 MD0000201063	Show NH Local Choice HMO Bronze 6500 SOB	Show NH Local Choice HMO Bronze 6500 SBC

RX: RX0000201017 Vision: VS0000201007
NH Local Choice HMO Bronze 7200 MD0000201064	Show NH Local Choice HMO Bronze 7200 SOB	Show NH Local Choice HMO Bronze 7200 SBC

RX: RX0000201018 Vision: VS0000201024
NH Local Choice HMO Bronze 8000 MD0000201060	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000201020 Vision: VS0000201004
NH Local Choice HMO HSA Silver 3500 MD0000201055	Show NH Local Choice HMO HSA Silver 3500 SOB	Show NH Local Choice HMO HSA Silver 3500 SBC

RX: RX0000201021 Vision: VS0000201009
NH Local Choice HMO HSA Bronze 6000 MD0000201042	Show NH Local Choice HMO HSA Bronze 6000 SOB	Show NH Local Choice HMO HSA Bronze 6000 SBC

RX: RX0000201022 Vision: VS0000201009

HMO - OFF EXCHANGE without Dental	SOB	SBC
NH Local Choice HMO Gold MD0000201040	Show NH Local Choice HMO Gold SOB	Show NH Local Choice HMO Gold SBC

RX: RX0000201008 Vision: VS0000201024
NH Local Choice HMO Gold 1400 MD0000201034	Show NH Local Choice HMO Gold 1400 SOB	Show NH Local Choice HMO Gold 1400 SBC

RX: RX0000201010 Vision: VS0000201003
NH Local Choice HMO Silver 2500 MD0000201023	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000201011 Vision: VS0000201004
NH Local Choice HMO Silver 3500 MD0000201024	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000201012 Vision: VS0000201005
NH Local Choice HMO Silver 4000 MD0000201039	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000201014 Vision: VS0000201006
NH Local Choice HMO Silver 5000 MD0000201041	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000201015 Vision: VS0000201005
NH Local Choice HMO Bronze 6500 MD0000201063	Show NH Local Choice HMO Bronze 6500 SOB	Show NH Local Choice HMO Bronze 6500 SBC

RX: RX0000201017 Vision: VS0000201007
NH Local Choice HMO Bronze 7200 MD0000201064	Show NH Local Choice HMO Bronze 7200 SOB	Show NH Local Choice HMO Bronze 7200 SBC

RX: RX0000201018 Vision: VS0000201024
NH Local Choice HMO Bronze 8000 MD0000201060	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000201020 Vision: VS0000201004
NH Local Choice HMO HSA Silver 3500 MD0000201055	Show NH Local Choice HMO HSA Silver 3500 SOB	Show NH Local Choice HMO HSA Silver 3500 SBC

RX: RX0000201021 Vision: VS0000201009
NH Local Choice HMO HSA Bronze 6000 MD0000201042	Show NH Local Choice HMO HSA Bronze 6000 SOB	Show NH Local Choice HMO HSA Bronze 6000 SBC

RX: RX0000201022 Vision: VS0000201009
NH Local HMO Gold 1500 Standard MD0000201043	Show NH Local HMO Gold 1500 Standard SOB	Show NH Local HMO Gold 1500 Standard SBC

RX: RX0000201023 Vision: VS0000201024
NH Local HMO Silver 5900 Standard MD0000201027	Show NH Local HMO Silver 5900 Standard SOB	Show NH Local HMO Silver 5900 Standard SBC

RX: RX0000201025 Vision: VS0000201004
NH Local HMO Bronze 7500 Standard MD0000201028	Show NH Local HMO Bronze 7500 Standard SOB	Show NH Local HMO Bronze 7500 Standard SBC

RX: RX0000201034 Vision: VS0000201010

HMO - ON EXCHANGE without Dental	SOB	SBC
NH Local Choice HMO Gold MD0000201040	Show NH Local Choice HMO Gold SOB	Show NH Local Choice HMO Gold SBC

RX: RX0000201008 Vision: VS0000201024
NH Local Choice HMO Gold 1400 MD0000201034	Show NH Local Choice HMO Gold 1400 SOB	Show NH Local Choice HMO Gold 1400 SBC

RX: RX0000201010 Vision: VS0000201003
NH Local Choice HMO Silver 2500 MD0000201023	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000201011 Vision: VS0000201004
NH Local Choice HMO Silver 3500 MD0000201024	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000201012 Vision: VS0000201005
NH Local Choice HMO Silver 4000 MD0000201039	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000201014 Vision: VS0000201006
NH Local Choice HMO Silver 5000 MD0000201041	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000201015 Vision: VS0000201005
NH Local Choice HMO Bronze 6500 MD0000201063	Show NH Local Choice HMO Bronze 6500 SOB	Show NH Local Choice HMO Bronze 6500 SBC

RX: RX0000201017 Vision: VS0000201007
NH Local Choice HMO Bronze 7200 MD0000201064	Show NH Local Choice HMO Bronze 7200 SOB	Show NH Local Choice HMO Bronze 7200 SBC

RX: RX0000201018 Vision: VS0000201024
NH Local Choice HMO Bronze 8000 MD0000201060	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000201020 Vision: VS0000201004
NH Local Choice HMO HSA Bronze 6000 MD0000201042	Show NH Local Choice HMO HSA Bronze 6000 SOB	Show NH Local Choice HMO HSA Bronze 6000 SBC

RX: RX0000201022 Vision: VS0000201009
NH Local HMO Gold 1500 Standard MD0000201043	Show NH Local HMO Gold 1500 Standard SOB	Show NH Local HMO Gold 1500 Standard SBC

RX: RX0000201023 Vision: VS0000201024
NH Local HMO Silver 5900 Standard MD0000201027	Show NH Local HMO Silver 5900 Standard SOB	Show NH Local HMO Silver 5900 Standard SBC

RX: RX0000201025 Vision: VS0000201004
NH Local HMO Bronze 7500 Standard MD0000201028	Show NH Local HMO Bronze 7500 Standard SOB	Show NH Local HMO Bronze 7500 Standard SBC

RX: RX0000201034 Vision: VS0000201010

HMO - ON EXCHANGE without Dental - AI/AN - limited	SOB	SBC
NH Local Choice HMO Gold MD0000201040	Show NH Local Choice HMO Gold SOB	Show NH Local Choice HMO Gold SBC

RX: RX0000201008 Vision: VS0000201024
NH Local Choice HMO Gold 1400 MD0000201034	Show NH Local Choice HMO Gold 1400 SOB	Show NH Local Choice HMO Gold 1400 SBC

RX: RX0000201010 Vision: VS0000201003
NH Local Choice HMO Silver 2500 MD0000201023	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000201011 Vision: VS0000201004
NH Local Choice HMO Silver 3500 MD0000201024	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000201012 Vision: VS0000201005
NH Local Choice HMO Silver 4000 MD0000201039	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000201014 Vision: VS0000201006
NH Local Choice HMO Silver 5000 MD0000201041	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000201015 Vision: VS0000201005
NH Local Choice HMO Bronze 6500 MD0000201063	Show NH Local Choice HMO Bronze 6500 SOB	Show NH Local Choice HMO Bronze 6500 SBC

RX: RX0000201017 Vision: VS0000201007
NH Local Choice HMO Bronze 7200 MD0000201064	Show NH Local Choice HMO Bronze 7200 SOB	Show NH Local Choice HMO Bronze 7200 SBC

RX: RX0000201018 Vision: VS0000201024
NH Local Choice HMO Bronze 8000 MD0000201060	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000201020 Vision: VS0000201004
NH Local Choice HMO Bronze 6000 MD0000201239	Show NH Local Choice HMO Bronze 6000 SOB	Show NH Local Choice HMO Bronze 6000 SBC

RX: RX0000201022 Vision: VS0000201009
NH Local HMO Gold 1500 Standard MD0000201043	Show NH Local HMO Gold 1500 Standard SOB	Show NH Local HMO Gold 1500 Standard SBC

RX: RX0000201023 Vision: VS0000201024
NH Local HMO Silver 5900 Standard MD0000201027	Show NH Local HMO Silver 5900 Standard SOB	Show NH Local HMO Silver 5900 Standard SBC

RX: RX0000201025 Vision: VS0000201004
NH Local HMO Bronze 7500 Standard MD0000201028	Show NH Local HMO Bronze 7500 Standard SOB	Show NH Local HMO Bronze 7500 Standard SBC

RX: RX0000201034 Vision: VS0000201010

HMO - ON EXCHANGE without Dental - AI/AN - $0 cost	SOB	SBC
NH Local Choice HMO CSR100 MD0000201062	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201009 Vision: VS0000201025
NH Local Choice HMO CSR100 MD0000201062	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201009 Vision: VS0000201025
NH Local Choice HMO CSR100 MD0000201062	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201009 Vision: VS0000201025
NH Local Choice HMO CSR100 MD0000201062	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201009 Vision: VS0000201025
NH Local Choice HMO CSR100 MD0000201062	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201009 Vision: VS0000201025
NH Local Choice HMO CSR100 MD0000201062	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201009 Vision: VS0000201025
NH Local Choice HMO CSR100 MD0000201062	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201009 Vision: VS0000201025
NH Local Choice HMO CSR100 MD0000201062	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201009 Vision: VS0000201025
NH Local Choice HMO CSR100 MD0000201062	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201009 Vision: VS0000201025
NH Local Choice HMO CSR100 MD0000201062	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201009 Vision: VS0000201025
NH Local HMO CSR100 MD0000201065	Show NH Local HMO CSR100 SOB	Show NH Local HMO CSR100 SBC

RX: RX0000201024 Vision: VS0000201025
NH Local HMO CSR100 MD0000201065	Show NH Local HMO CSR100 SOB	Show NH Local HMO CSR100 SBC

RX: RX0000201024 Vision: VS0000201025
NH Local HMO CSR100 MD0000201065	Show NH Local HMO CSR100 SOB	Show NH Local HMO CSR100 SBC

RX: RX0000201024 Vision: VS0000201025

HMO - ON EXCHANGE without Dental - CSR - 73%	SOB	SBC
NH Local Choice HMO Silver 2500 CSR73 MD0000201038	Show NH Local Choice HMO Silver 2500 CSR73 SOB	Show NH Local Choice HMO Silver 2500 CSR73 SBC

RX: RX0000201038 Vision: VS0000201011
NH Local Choice HMO Silver 3000 CSR73 MD0000201031	Show NH Local Choice HMO Silver 3000 CSR73 SOB	Show NH Local Choice HMO Silver 3000 CSR73 SBC

RX: RX0000201041 Vision: VS0000201011
NH Local Choice HMO Silver 2800 CSR73 MD0000201048	Show NH Local Choice HMO Silver 2800 CSR73 SOB	Show NH Local Choice HMO Silver 2800 CSR73 SBC

RX: RX0000201044 Vision: VS0000201015
NH Local Choice HMO Silver 3400 CSR73 MD0000201029	Show NH Local Choice HMO Silver 3400 CSR73 SOB	Show NH Local Choice HMO Silver 3400 CSR73 SBC

RX: RX0000201028 Vision: VS0000201017
NH Local HMO Silver 5700 Standard CSR73 MD0000201044	Show NH Local HMO Silver 5700 Standard CSR73 SOB	Show NH Local HMO Silver 5700 Standard CSR73 SBC

RX: RX0000201035 Vision: VS0000201021

HMO - ON EXCHANGE without Dental - CSR - 87%	SOB	SBC
NH Local Choice HMO Silver 1000 CSR87 MD0000201037	Show NH Local Choice HMO Silver 1000 CSR87 SOB	Show NH Local Choice HMO Silver 1000 CSR87 SBC

RX: RX0000201039 Vision: VS0000201012
NH Local Choice HMO Silver Copay 1200 CSR87 MD0000201046	Show NH Local Choice HMO Silver Copay 1200 CSR87 SOB	Show NH Local Choice HMO Silver Copay 1200 CSR87 SBC

RX: RX0000201042 Vision: VS0000201014
NH Local Choice HMO Silver 1100 CSR87 MD0000201050	Show NH Local Choice HMO Silver 1100 CSR87 SOB	Show NH Local Choice HMO Silver 1100 CSR87 SBC

RX: RX0000201026 Vision: VS0000201016
NH Local Choice HMO Silver 1400 CSR87 MD0000201049	Show NH Local Choice HMO Silver 1400 CSR87 SOB	Show NH Local Choice HMO Silver 1400 CSR87 SBC

RX: RX0000201029 Vision: VS0000201014
NH Local HMO Silver 700 Standard CSR87 MD0000201045	Show NH Local HMO Silver 700 Standard CSR87 SOB	Show NH Local HMO Silver 700 Standard CSR87 SBC

RX: RX0000201036 Vision: VS0000201022

HMO - ON EXCHANGE without Dental - CSR - 94%	SOB	SBC
NH Local Choice HMO Silver 300 CSR94 MD0000201036	Show NH Local Choice HMO Silver 300 CSR94 SOB	Show NH Local Choice HMO Silver 300 CSR94 SBC

RX: RX0000201040 Vision: VS0000201013
NH Local Choice HMO Silver Copay 400 CSR94 MD0000201035	Show NH Local Choice HMO Silver Copay 400 CSR94 SOB	Show NH Local Choice HMO Silver Copay 400 CSR94 SBC

RX: RX0000201043 Vision: VS0000201013
NH Local Choice HMO Silver 350 CSR94 MD0000201033	Show NH Local Choice HMO Silver 350 CSR94 SOB	Show NH Local Choice HMO Silver 350 CSR94 SBC

RX: RX0000201027 Vision: VS0000201013
NH Local Choice HMO Silver 450 CSR94 MD0000201051	Show NH Local Choice HMO Silver 450 CSR94 SOB	Show NH Local Choice HMO Silver 450 CSR94 SBC

RX: RX0000201030 Vision: VS0000201013
NH Local HMO Silver Standard CSR94 MD0000201047	Show NH Local HMO Silver Standard CSR94 SOB	Show NH Local HMO Silver Standard CSR94 SBC

RX: RX0000201037 Vision: VS0000201023

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Individual Market effective 1/1/24

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Individual Market effective 1/1/24