Schedules of Benefits and SBCs: New Hampshire

Individual Market effective 1/1/25

HMO - OFF EXCHANGE without Dental	SOB	SBC
NH Local HMO Gold 1500 Standard MD0000201317	Show NH Local HMO Gold 1500 Standard SOB	Show NH Local HMO Gold 1500 Standard SBC

RX: RX0000201170 Vision: VS0000201106
NH Local HMO Silver 5000 Standard MD0000201319	Show NH Local HMO Silver 5000 Standard SOB	Show NH Local HMO Silver 5000 Standard SBC

RX: RX0000201168 Vision: VS0000201103
NH Local HMO Bronze 7500 Standard MD0000201324	Show NH Local HMO Bronze 7500 Standard SOB	Show NH Local HMO Bronze 7500 Standard SBC

RX: RX0000201173 Vision: VS0000201108
NH Local Choice HMO HSA Silver 3500 MD0000201321	Show NH Local Choice HMO HSA Silver 3500 SOB	Show NH Local Choice HMO HSA Silver 3500 SBC

RX: RX0000201167 Vision: VS0000201105
NH Local Choice HMO HSA Bronze 6000 MD0000201323	Show NH Local Choice HMO HSA Bronze 6000 SOB	Show NH Local Choice HMO HSA Bronze 6000 SBC

RX: RX0000201172 Vision: VS0000201105
NH Local Choice HMO Gold MD0000201327	Show NH Local Choice HMO Gold SOB	Show NH Local Choice HMO Gold SBC

RX: RX0000201175 Vision: VS0000201110
NH Local Choice HMO Gold 1400 MD0000201328	Show NH Local Choice HMO Gold 1400 SOB	Show NH Local Choice HMO Gold 1400 SBC

RX: RX0000201176 Vision: VS0000201105
NH Local Choice HMO Silver 2500 MD0000201329	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000201192 Vision: VS0000201102
NH Local Choice HMO Silver 3500 MD0000201334	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000201178 Vision: VS0000201114
NH Local Choice HMO Silver 4000 MD0000201338	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000201182 Vision: VS0000201117
NH Local Choice HMO Silver 5000 MD0000201346	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000201196 Vision: VS0000201119
NH Local Choice HMO Bronze 6500 MD0000201351	Show NH Local Choice HMO Bronze 6500 SOB	Show NH Local Choice HMO Bronze 6500 SBC

RX: RX0000201188 Vision: VS0000201121
NH Local Choice HMO Bronze 7200 MD0000201352	Show NH Local Choice HMO Bronze 7200 SOB	Show NH Local Choice HMO Bronze 7200 SBC

RX: RX0000201189 Vision: VS0000201110
NH Local Choice HMO Bronze 8000 MD0000201318	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000201197 Vision: VS0000201102

HMO - ON EXCHANGE without Dental	SOB	SBC
NH Local HMO Gold 1500 Standard MD0000201317	Show NH Local HMO Gold 1500 Standard SOB	Show NH Local HMO Gold 1500 Standard SBC

RX: RX0000201170 Vision: VS0000201106
NH Local HMO Silver 5000 Standard MD0000201319	Show NH Local HMO Silver 5000 Standard SOB	Show NH Local HMO Silver 5000 Standard SBC

RX: RX0000201168 Vision: VS0000201103
NH Local HMO Bronze 7500 Standard MD0000201324	Show NH Local HMO Bronze 7500 Standard SOB	Show NH Local HMO Bronze 7500 Standard SBC

RX: RX0000201173 Vision: VS0000201108
NH Local Choice HMO HSA Bronze 6000 MD0000201323	Show NH Local Choice HMO HSA Bronze 6000 SOB	Show NH Local Choice HMO HSA Bronze 6000 SBC

RX: RX0000201172 Vision: VS0000201105
NH Local Choice HMO Gold MD0000201327	Show NH Local Choice HMO Gold SOB	Show NH Local Choice HMO Gold SBC

RX: RX0000201175 Vision: VS0000201110
NH Local Choice HMO Gold 1400 MD0000201328	Show NH Local Choice HMO Gold 1400 SOB	Show NH Local Choice HMO Gold 1400 SBC

RX: RX0000201176 Vision: VS0000201105
NH Local Choice HMO Silver 3500 MD0000201334	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000201178 Vision: VS0000201114
NH Local Choice HMO Silver 5000 MD0000201346	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000201196 Vision: VS0000201119
NH Local Choice HMO Bronze 8000 MD0000201318	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000201197 Vision: VS0000201102

HMO - ON EXCHANGE without Dental - AI/AN - Limited	SOB	SBC
NH Local HMO Gold 1500 Standard MD0000201317	Show NH Local HMO Gold 1500 Standard SOB	Show NH Local HMO Gold 1500 Standard SBC

RX: RX0000201170 Vision: VS0000201106
NH Local HMO Silver 5000 Standard MD0000201319	Show NH Local HMO Silver 5000 Standard SOB	Show NH Local HMO Silver 5000 Standard SBC

RX: RX0000201168 Vision: VS0000201103
NH Local HMO Bronze 7500 Standard MD0000201324	Show NH Local HMO Bronze 7500 Standard SOB	Show NH Local HMO Bronze 7500 Standard SBC

RX: RX0000201173 Vision: VS0000201108
NH Local Choice HMO Bronze 6000 MD0000201325	Show NH Local Choice HMO Bronze 6000 SOB	Show NH Local Choice HMO Bronze 6000 SBC

RX: RX0000201172 Vision: VS0000201105
NH Local Choice HMO Gold MD0000201327	Show NH Local Choice HMO Gold SOB	Show NH Local Choice HMO Gold SBC

RX: RX0000201175 Vision: VS0000201110
NH Local Choice HMO Gold 1400 MD0000201328	Show NH Local Choice HMO Gold 1400 SOB	Show NH Local Choice HMO Gold 1400 SBC

RX: RX0000201176 Vision: VS0000201105
NH Local Choice HMO Silver 3500 MD0000201334	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000201178 Vision: VS0000201114
NH Local Choice HMO Silver 5000 MD0000201346	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000201196 Vision: VS0000201119
NH Local Choice HMO Bronze 8000 MD0000201318	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000201197 Vision: VS0000201102

HMO - ON EXCHANGE without Dental - AI/AN - $0 Cost	SOB	SBC
NH Local HMO CSR100 MD0000201350	Show NH Local HMO CSR100 SOB	Show NH Local HMO CSR100 SBC

RX: RX0000201190 Vision: VS0000201122
NH Local HMO CSR100 MD0000201350	Show NH Local HMO CSR100 SOB	Show NH Local HMO CSR100 SBC

RX: RX0000201190 Vision: VS0000201122
NH Local HMO CSR100 MD0000201350	Show NH Local HMO CSR100 SOB	Show NH Local HMO CSR100 SBC

RX: RX0000201190 Vision: VS0000201122
NH Local Choice HMO CSR100 MD0000201344	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201191 Vision: VS0000201122
NH Local Choice HMO CSR100 MD0000201344	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201191 Vision: VS0000201122
NH Local Choice HMO CSR100 MD0000201344	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201191 Vision: VS0000201122
NH Local Choice HMO CSR100 MD0000201344	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201191 Vision: VS0000201122
NH Local Choice HMO CSR100 MD0000201344	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201191 Vision: VS0000201122
NH Local Choice HMO CSR100 MD0000201344	Show NH Local Choice HMO CSR100 SOB	Show NH Local Choice HMO CSR100 SBC

RX: RX0000201191 Vision: VS0000201122

HMO - ON EXCHANGE without Dental - CSR - 73%	SOB	SBC
NH Local HMO Silver 3000 Standard CSR73 MD0000201322	Show NH Local HMO Silver 3000 Standard CSR73 SOB	Show NH Local HMO Silver 3000 Standard CSR73 SBC

RX: RX0000201171 Vision: VS0000201107
NH Local Choice HMO Silver 2400 CSR73 MD0000201335	Show NH Local Choice HMO Silver 2400 CSR73 SOB	Show NH Local Choice HMO Silver 2400 CSR73 SBC

RX: RX0000201179 Vision: VS0000201111
NH Local Choice HMO Silver 3400 CSR73 MD0000201343	Show NH Local Choice HMO Silver 3400 CSR73 SOB	Show NH Local Choice HMO Silver 3400 CSR73 SBC

RX: RX0000201185 Vision: VS0000201120

HMO - ON EXCHANGE without Dental - CSR - 87%	SOB	SBC
NH Local HMO Silver 500 Standard CSR87 MD0000201320	Show NH Local HMO Silver 500 Standard CSR87 SOB	Show NH Local HMO Silver 500 Standard CSR87 SBC

RX: RX0000201169 Vision: VS0000201104
NH Local Choice HMO Silver Copay 1200 CSR87 MD0000201336	Show NH Local Choice HMO Silver Copay 1200 CSR87 SOB	Show NH Local Choice HMO Silver Copay 1200 CSR87 SBC

RX: RX0000201180 Vision: VS0000201116
NH Local Choice HMO Silver 1400 CSR87 MD0000201347	Show NH Local Choice HMO Silver 1400 CSR87 SOB	Show NH Local Choice HMO Silver 1400 CSR87 SBC

RX: RX0000201186 Vision: VS0000201116

HMO - ON EXCHANGE without Dental - CSR - 94%	SOB	SBC
NH Local HMO Silver Standard CSR94 MD0000201326	Show NH Local HMO Silver Standard CSR94 SOB	Show NH Local HMO Silver Standard CSR94 SBC

RX: RX0000201174 Vision: VS0000201109
NH Local Choice HMO Silver Copay 400 CSR94 MD0000201337	Show NH Local Choice HMO Silver Copay 400 CSR94 SOB	Show NH Local Choice HMO Silver Copay 400 CSR94 SBC

RX: RX0000201181 Vision: VS0000201113
NH Local Choice HMO Silver 450 CSR94 MD0000201348	Show NH Local Choice HMO Silver 450 CSR94 SOB	Show NH Local Choice HMO Silver 450 CSR94 SBC

RX: RX0000201187 Vision: VS0000201113

HMO - OFF EXCHANGE with Dental	SOB	SBC
NH Local Choice HMO HSA Silver 3500 MD0000201321	Show NH Local Choice HMO HSA Silver 3500 SOB	Show NH Local Choice HMO HSA Silver 3500 SBC

RX: RX0000201167 Vision: VS0000201105
NH Local Choice HMO HSA Bronze 6000 MD0000201323	Show NH Local Choice HMO HSA Bronze 6000 SOB	Show NH Local Choice HMO HSA Bronze 6000 SBC

RX: RX0000201172 Vision: VS0000201105
NH Local Choice HMO Gold MD0000201327	Show NH Local Choice HMO Gold SOB	Show NH Local Choice HMO Gold SBC

RX: RX0000201175 Vision: VS0000201110
NH Local Choice HMO Gold 1400 MD0000201328	Show NH Local Choice HMO Gold 1400 SOB	Show NH Local Choice HMO Gold 1400 SBC

RX: RX0000201176 Vision: VS0000201105
NH Local Choice HMO Silver 2500 MD0000201329	Show NH Local Choice HMO Silver 2500 SOB	Show NH Local Choice HMO Silver 2500 SBC

RX: RX0000201192 Vision: VS0000201102
NH Local Choice HMO Silver 3500 MD0000201333	Show NH Local Choice HMO Silver 3500 SOB	Show NH Local Choice HMO Silver 3500 SBC

RX: RX0000201178 Vision: VS0000201114
NH Local Choice HMO Silver 4000 MD0000201338	Show NH Local Choice HMO Silver 4000 SOB	Show NH Local Choice HMO Silver 4000 SBC

RX: RX0000201182 Vision: VS0000201117
NH Local Choice HMO Silver 5000 MD0000201345	Show NH Local Choice HMO Silver 5000 SOB	Show NH Local Choice HMO Silver 5000 SBC

RX: RX0000201196 Vision: VS0000201119
NH Local Choice HMO Bronze 6500 MD0000201351	Show NH Local Choice HMO Bronze 6500 SOB	Show NH Local Choice HMO Bronze 6500 SBC

RX: RX0000201188 Vision: VS0000201121
NH Local Choice HMO Bronze 7200 MD0000201352	Show NH Local Choice HMO Bronze 7200 SOB	Show NH Local Choice HMO Bronze 7200 SBC

RX: RX0000201189 Vision: VS0000201110
NH Local Choice HMO Bronze 8000 MD0000201318	Show NH Local Choice HMO Bronze 8000 SOB	Show NH Local Choice HMO Bronze 8000 SBC

RX: RX0000201197 Vision: VS0000201102

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