{"text_format":"1","workbook":"xlsx","n_sheets":30,"sheets":["EnableMacros","Benefits Package 1","Cost Share Variances 1","Benefits Package 2","Cost Share Variances 2","Benefits Package 3","Cost Share Variances 3","Benefits Package 4","Cost Share Variances 4","Benefits Package 5","Cost Share Variances 5","Benefits Package 6","Cost Share Variances 6","Benefits Package 7","Cost Share Variances 7","Benefits Package 8","Cost Share Variances 8","Benefits Package 9","Cost Share Variances 9","Benefits Package 10","Cost Share Variances 10","Benefits Package 11","Cost Share Variances 11","Benefits Package 12","Cost Share Variances 12","Benefits Package 13","Cost Share Variances 13","DefaultBP","DefaultCSV","Names"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":94,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"EnableMacros","index":0,"n_rows":17,"n_cols":2,"rows_kept":17,"cut":false,"hidden":true,"merged":[[0,0,0,15],[1,0,1,15],[2,0,2,15]]}
["Plans & Benefits Template"]
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[null,"If you are seeing this sheet, macros are not enabled, please follow the following steps: "]
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[null,"If using Excel 2007 and 2010:"]
[null,"1. Set the macro security setting to Disable macros with notifications (Recommended) or Enable all macros. To change"]
[null,"    the macro security setting, click the Office Button and select Excel Option -> Trust Center -> Trust Center Settings -> "]
[null,"    Macro Settings."]
[null,"2. If the macro security setting is set to Disable macros with notifications, click the Option button and select Enable this "]
[null,"    content."]
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[null,"Note: This screen will flash momentarily when you save or finalize this workbook."]

{"sheet":"Benefits Package 1","index":1,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[126,0,126,1],[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[124,0,124,1],[125,0,125,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[127,0,127,1],[128,0,128,1],[129,0,129,1],[130,0,130,1],[131,0,131,1],[137,0,137,1],[138,0,138,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[136,0,136,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1250004","HMO Blue New England Premier Value","42690MA125","MAN001","MAS001","MAF006","Existing","HMO","Gold","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290024","HMO Blue New England Basic Copayment","42690MA129","MAN001","MAS001","MAF009","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290085","HMO Blue New England Total Deductible with RX","42690MA129","MAN001","MAS001","MAF016","Existing","HMO","Gold","Not Applicable","Yes","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
["HIOS Plan ID \n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","CSR Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1250004-00","HMO Blue New England Premier Value","Gold","Standard Gold Off Exchange Plan",null,0.80143402296948196,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,1000,10,0,60,0,3100,0,20,0,600,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8750,"$8750 per person | $17500 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",1000,"$1000 per person | $2500 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,250,null,250,"Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,75,null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,300,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.35,null,1,75,null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1]
["42690MA1290024-00","HMO Blue New England Basic Copayment","Silver","Standard Silver Off Exchange Plan",null,0.70783132385915304,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,2000,1100,0,60,100,3600,0,20,2000,400,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9100,"$9100 per person | $18200 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",2000,"$2000 per person | $4000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,45,null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"$1000.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,175,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,175,null,"Not Applicable","Not Applicable",null,1]
["42690MA1290085-00","HMO Blue New England Total Deductible with RX","Gold","Standard Gold Off Exchange Plan",0.78380000000000005,0.76611969743932495,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,3500,10,0,60,900,2600,0,20,1900,10,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7000,"$7000 per person | $14000 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",3500,"$3500 per person | $7000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,125,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,125,null,"Not Applicable","Not Applicable",null,1]

{"sheet":"Benefits Package 2","index":3,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1290008","HMO Blue New England $2,000 Deductible","42690MA129","MAN001","MAS001","MAF006","Existing","HMO","Gold","Not Applicable","Yes","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290026","HMO Blue New England $3,000 Deductible","42690MA129","MAN001","MAS001","MAF006","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290081","HMO Blue New England $4,500 Deductible","42690MA129","MAN001","MAS001","MAF006","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290086","HMO Blue New England $5,000 Deductible","42690MA129","MAN001","MAS001","MAF006","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
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Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1290008-00","HMO Blue New England $2,000 Deductible","Gold","Standard Gold Off Exchange Plan",0.78180000000000005,0.76358999669398298,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,2000,500,0,60,100,3100,0,20,2000,200,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8750,"$8750 per person | $17500 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",2000,"$2000 per person | $4000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"$250.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable",0.5,null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1]
["42690MA1290026-00","HMO Blue New England $3,000 Deductible","Silver","Standard Silver Off Exchange Plan",null,0.71158655308307595,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,3000,800,0,60,100,3200,0,20,2300,100,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9100,"$9100 per person | $18200 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",3000,"$3000 per person | $6000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,45,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"$750.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable",0.5,null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1]
["42690MA1290081-00","HMO Blue New England $4,500 Deductible","Silver","Standard Silver Off Exchange Plan",null,0.70977404363626895,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,4500,800,0,60,100,3200,0,20,1400,100,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8750,"$8750 per person | $17500 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",4500,"$4500 per person | $9000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,45,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"$500.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable",0.5,null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1]
["42690MA1290086-00","HMO Blue New England $5,000 Deductible","Silver","Standard Silver Off Exchange Plan",null,0.70965143962444999,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,5000,1000,0,60,100,3200,0,20,1400,100,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8750,"$8750 per person | $17500 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",5000,"$5000 per person | $10000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,40,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"$500.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable",0.5,null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1]

{"sheet":"Benefits Package 3","index":5,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1290080","HMO Blue New England $1,000 Deductible with Copayment","42690MA129","MAN001","MAS001","MAF005","Existing","HMO","Gold","Not Applicable","Yes","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290079","HMO Blue New England $2,000 Deductible with Copayment","42690MA129","MAN001","MAS001","MAF012","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290050","HMO Blue New England $1,500 Deductible with Copayment","42690MA129","MAN001","MAS001","MAF011","New","HMO","Gold","Not Applicable","Yes","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290088","HMO Blue New England $3,000 Deductible with Copayment","42690MA129","MAN001","MAS001","MAF006","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
["HIOS Plan ID \n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","CSR Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1290080-00","HMO Blue New England $1,000 Deductible with Copayment","Gold","Standard Gold Off Exchange Plan",0.78269999999999995,0.76368148229106203,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,1000,600,0,60,100,2400,0,20,1000,500,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8750,"$8750 per person | $17500 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",1000,"$1000 per person | $2000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"$250.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$550.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,100,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$80.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$550.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,100,null,"Not Applicable","Not Applicable",null,1]
["42690MA1290079-00","HMO Blue New England $2,000 Deductible with Copayment","Silver","Standard Silver Off Exchange Plan",null,0.712092957846443,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,2000,900,0,60,100,4100,0,20,2000,300,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9100,"$9100 per person | $18200 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",2000,"$2000 per person | $4000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1200.00 Copay after deductible",null,"$1200.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,275,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$200.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,275,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1]
["42690MA1290050-00","HMO Blue New England $1,500 Deductible with Copayment","Gold","Standard Gold Off Exchange Plan",0.78159999999999996,0.77331240308254401,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,1500,1100,0,60,100,3500,0,20,1500,800,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,6000,"$6000 per person | $12000 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",1500,"$1500 per person | $3000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,30,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"$750.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,175,null,"Not Applicable","Not Applicable",null,1,200,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$600.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,200,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,175,null,"Not Applicable","Not Applicable",null,1]
["42690MA1290088-00","HMO Blue New England $3,000 Deductible with Copayment","Silver","Standard Silver Off Exchange Plan",null,0.71097599461394201,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,3000,1600,0,60,100,3200,0,20,2300,100,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9000,"$9000 per person | $18000 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",3000,"$3000 per person | $6000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,45,null,"Not Applicable","Not Applicable",null,1,70,null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,70,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"$750.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"$70.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$70.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,70,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,70,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$70.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$70.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,70,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,70,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,70,null,"Not Applicable","Not Applicable",null,1,70,null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,70,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$70.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,70,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1]

{"sheet":"Benefits Package 4","index":7,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1290005","HMO Blue New England $500 Deductible with HCCS","42690MA129","MAN001","MAS001","MAF006","Existing","HMO","Gold","Not Applicable","Yes","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290067","HMO Blue New England $1,500 Deductible with HCCS","42690MA129","MAN001","MAS001","MAF006","Existing","HMO","Gold","Not Applicable","Yes","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
["HIOS Plan ID \n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","CSR Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1290005-00","HMO Blue New England $500 Deductible with HCCS","Gold","Standard Gold Off Exchange Plan",0.7802,0.77052223558954902,"No","Yes","Yes","All specialists except OB/GYN providers ","Yes",0.9,0.1,500,400,0,60,100,3100,0,20,500,500,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",8500,"$8500 per person | $17000 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",500,"$500 per person | $1000 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,30,30,"Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,30,30,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$250.00 Copay after deductible","$250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","No Charge","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay after deductible","$250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,30,30,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,30,30,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,45,45,"Not Applicable","Not Applicable","Not Applicable",1,150,150,"Not Applicable","Not Applicable","Not Applicable",1,225,225,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.5,0.5,1,"$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","35.00% Coinsurance after deductible","35.00% Coinsurance after deductible",1,"$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$135.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,225,225,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$45.00 Copay after deductible","$45.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,150,150,"Not Applicable","Not Applicable","Not Applicable",1]
["42690MA1290067-00","HMO Blue New England $1,500 Deductible with HCCS","Gold","Standard Gold Off Exchange Plan",0.78010000000000002,0.77337171912641101,"No","Yes","Yes","All specialists except OB/GYN providers ","Yes",0.9,0.1,1500,300,0,60,100,3100,0,20,1400,100,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",7250,"$7250 per person | $14500 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",1500,"$1500 per person | $3000 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,25,"Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$250.00 Copay after deductible","$250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","No Charge","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay after deductible","$250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,45,45,"Not Applicable","Not Applicable","Not Applicable",1,150,150,"Not Applicable","Not Applicable","Not Applicable",1,225,225,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.5,0.5,1,"$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","35.00% Coinsurance after deductible","35.00% Coinsurance after deductible",1,"$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$135.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,225,225,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$45.00 Copay after deductible","$45.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,150,150,"Not Applicable","Not Applicable","Not Applicable",1]

{"sheet":"Benefits Package 5","index":9,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1290007","HMO Blue New England $2,000 Deductible with HCCS","42690MA129","MAN001","MAS001","MAF006","Existing","HMO","Gold","Not Applicable","Yes","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290027","HMO Blue New England $3,000 Deductible with HCCS","42690MA129","MAN001","MAS001","MAF012","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290074","HMO Blue New England Saver $3,000 with HCCS","42690MA129","MAN001","MAS001","MAF001","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
["HIOS Plan ID \n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","CSR Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1290007-00","HMO Blue New England $2,000 Deductible with HCCS","Gold","Standard Gold Off Exchange Plan",0.78010000000000002,0.77397305333519351,"No","Yes","Yes","All specialists except OB/GYN providers ","Yes",0.9,0.1,2000,300,0,60,100,3100,0,20,2000,300,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",6750,"$6750 per person | $13500 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",2000,"$2000 per person | $4000 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,25,"Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$250.00 Copay after deductible","$250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","No Charge after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Day after deductible","$250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,45,45,"Not Applicable","Not Applicable","Not Applicable",1,150,150,"Not Applicable","Not Applicable","Not Applicable",1,225,225,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.5,0.5,1,"$50.00 Copay after deductible","$90.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$50.00 Copay with deductible","$90.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","35.00% Coinsurance after deductible","35.00% Coinsurance after deductible",1,"$50.00 Copay after deductible","$90.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$50.00 Copay after deductible","$90.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$135.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,225,225,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$50.00 Copay after deductible","$50.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,50,50,"Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,150,150,"Not Applicable","Not Applicable","Not Applicable",1]
["42690MA1290027-00","HMO Blue New England $3,000 Deductible with HCCS","Silver","Standard Silver Off Exchange Plan",null,0.71571254502225734,"No","Yes","Yes","All specialists except OB/GYN providers ","Yes",0.9,0.1,3000,500,0,60,100,3800,0,20,1400,100,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",9100,"$9100 per person | $18200 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",3000,"$3000 per person | $6000 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,35,35,"Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,35,35,"Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$800.00 Copay after deductible","$800.00 Copay after deductible","$800.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","No Charge","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","$500.00 Copay per Stay after deductible","$1500.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay per Stay after deductible","$500.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,30,30,"Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay per Stay after deductible","$1500.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,30,30,"Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay per Stay after deductible","$1500.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,45,45,"Not Applicable","Not Applicable","Not Applicable",1,200,200,"Not Applicable","Not Applicable","Not Applicable",1,250,250,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.5,0.5,1,"$50.00 Copay after deductible","$90.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$50.00 Copay with deductible","$90.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay after deductible","$950.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","35.00% Coinsurance after deductible","35.00% Coinsurance after deductible",1,"$50.00 Copay after deductible","$90.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$50.00 Copay after deductible","$90.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$75.00 Copay after deductible","$175.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,250,250,"Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$50.00 Copay after deductible","$50.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,200,200,"Not Applicable","Not Applicable","Not Applicable",1]
["42690MA1290074-00","HMO Blue New England Saver $3,000 with HCCS","Silver","Standard Silver Off Exchange Plan",null,0.69413499612345575,"Yes","Yes","Yes","All specialists except OB/GYN providers ","Yes",0.9,0.1,3000,300,0,60,3000,1500,0,20,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",7150,"$7150 per person | $14300 per group",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",3000,"$6000 per person | $6000 per group","Yes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$35.00 Copay after deductible","$35.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$35.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$350.00 Copay after deductible","$350.00 Copay after deductible","$350.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","No Charge after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay after deductible","$250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$35.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$35.00 Copay after deductible","$35.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay after deductible","$1250.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$45.00 Copay after deductible","$45.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$150.00 Copay after deductible","$150.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$225.00 Copay after deductible","$225.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","50.00% Coinsurance after deductible","50.00% Coinsurance after deductible",1,"$50.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$50.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","35.00% Coinsurance after deductible","35.00% Coinsurance after deductible",1,"$50.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$50.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$15.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$25.00 Copay after deductible","$125.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$225.00 Copay after deductible","$225.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$50.00 Copay after deductible","$50.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$15.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$150.00 Copay after deductible","$150.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1]

{"sheet":"Benefits Package 6","index":11,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1270004","HMO Blue New England Options Deductible II","42690MA127","MAN001","MAS001","MAF010","Existing","HMO","Gold","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1270003","HMO Blue New England Options Deductible III","42690MA127","MAN001","MAS001","MAF010","Existing","HMO","Gold","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
["HIOS Plan ID \n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","CSR Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1270004-00","HMO Blue New England Options Deductible II","Gold","Standard Gold Off Exchange Plan",null,0.80572639302632665,"No","Yes","Yes","All specialists except OB/GYN providers ","Yes",0.8,0.2,1000,800,0,60,0,3500,0,20,1000,200,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",8750,"$8750 per person | $17500 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",1000,"$1000 per person | $2000 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,55,"Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$250.00 Copay after deductible","$250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","No Charge","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","$250.00 Copay per Stay after deductible","$2000.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay per Stay","$250.00 Copay per Stay","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$2000.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$2000.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,45,45,"Not Applicable","Not Applicable","Not Applicable",1,175,175,"Not Applicable","Not Applicable","Not Applicable",1,250,250,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.5,0.5,1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.2,0.2,1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$150.00 Copay after deductible","$500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.35,0.35,1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$15.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$25.00 Copay after deductible","$100.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.2,0.2,1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,250,250,"Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,55,55,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"$15.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,175,175,"Not Applicable","Not Applicable","Not Applicable",1]
["42690MA1270003-00","HMO Blue New England Options Deductible III","Gold","Standard Gold Off Exchange Plan",null,0.79740626518665425,"No","Yes","Yes","All specialists except OB/GYN providers ","Yes",0.8,0.2,2000,800,0,60,0,3500,0,20,1000,200,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",8750,"$8750 per person | $17500 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",2000,"$2000 per person | $4000 per group","Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,55,"Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$250.00 Copay after deductible","$250.00 Copay after deductible","$250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","No Charge","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","No Charge after deductible","$2000.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","$2000.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","$2000.00 Copay per Stay after deductible","Not Applicable","Not Applicable","Not Applicable",1,45,45,"Not Applicable","Not Applicable","Not Applicable",1,175,175,"Not Applicable","Not Applicable","Not Applicable",1,250,250,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.5,0.5,1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.2,0.2,1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$150.00 Copay after deductible","$500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.35,0.35,1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,25,25,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"$15.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"$25.00 Copay after deductible","$100.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"Not Applicable","Not Applicable","Not Applicable",0.2,0.2,1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,250,250,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge after deductible","$2000.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,55,55,"Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,60,60,"Not Applicable","Not Applicable","Not Applicable",1,"$15.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",1,175,175,"Not Applicable","Not Applicable","Not Applicable",1]

{"sheet":"Benefits Package 7","index":13,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1290084","HMO Blue New England Basic Saver","42690MA129","MAN001","MAS001","MAF003","Existing","HMO","Silver","Not Applicable","Yes","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290075","HMO Blue New England Saver $2,000","42690MA129","MAN001","MAS001","MAF003","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290076","HMO Blue New England Saver $3,000","42690MA129","MAN001","MAS001","MAF001","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1290083","HMO Blue New England Saver $4,500","42690MA129","MAN001","MAS001","MAF003","Existing","HMO","Silver","Not Applicable","Yes","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
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Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1290084-00","HMO Blue New England Basic Saver","Silver","Standard Silver Off Exchange Plan",0.6804,0.67642210653732704,"Yes","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,3350,1600,0,60,3350,1400,0,20,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7100,"$7100 per person | $14200 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3350,"$6550 per person | $6550 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Yes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"$1500.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$175.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$125.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$175.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1]
["42690MA1290075-00","HMO Blue New England Saver $2,000","Silver","Standard Silver Off Exchange Plan",null,0.69954823528069299,"Yes","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,2000,600,0,60,2000,2300,0,20,2000,300,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7150,"$7150 per person | $14300 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2000,"$4000 per person | $4000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Yes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$350.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$175.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$125.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$175.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1]
["42690MA1290076-00","HMO Blue New England Saver $3,000","Silver","Standard Silver Off Exchange Plan",null,0.68838499732387204,"Yes","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,3000,300,0,60,3000,1500,0,20,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7150,"$7150 per person | $14300 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3000,"$6000 per person | $6000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Yes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$350.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$225.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$400.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$100.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$225.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1]
["42690MA1290083-00","HMO Blue New England Saver $4,500","Silver","Standard Silver Off Exchange Plan",0.68,0.67744278977193095,"Yes","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,4500,1000,0,60,4500,600,0,20,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,6950,"$6950 per person | $13900 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,4500,"$9000 per person | $9000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Yes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"$500.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$175.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$175.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1]

{"sheet":"Benefits Package 8","index":15,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1390010","HMO Blue Select $1,000 Deductible with Copayment","42690MA139","MAN003","MAS003","MAF013","Existing","HMO","Gold","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1390009","HMO Blue Select $2,000 Deductible with Copayment","42690MA139","MAN003","MAS003","MAF014","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
["HIOS Plan ID \n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","CSR Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1390010-00","HMO Blue Select $1,000 Deductible with Copayment","Gold","Standard Gold Off Exchange Plan",null,0.78701248653947598,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,1000,1000,0,60,100,2100,0,20,1000,600,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,6950,"$6950 per person | $13900 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",1000,"$1000 per person | $2000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,350,null,350,"Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,80,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,80,null,"Not Applicable","Not Applicable",null,1]
["42690MA1390009-00","HMO Blue Select $2,000 Deductible with Copayment","Silver","Standard Silver Off Exchange Plan",null,0.71347959274753103,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,2000,1000,0,60,100,4100,0,20,2000,300,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9100,"$9100 per person | $18200 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",2000,"$2000 per person | $4000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,30,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$850.00 Copay after deductible",null,"$850.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,275,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$155.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,275,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1]

{"sheet":"Benefits Package 9","index":17,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1390003","HMO Blue Select $2,000 Deductible","42690MA139","MAN003","MAS003","MAF006","Existing","HMO","Gold","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1390005","HMO Blue Select $3,000 Deductible","42690MA139","MAN003","MAS003","MAF009","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
["42690MA1390007","HMO Blue Select Saver $2,000","42690MA139","MAN003","MAS003","MAF003","Existing","HMO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","No"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
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Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1390003-00","HMO Blue Select $2,000 Deductible","Gold","Standard Gold Off Exchange Plan",null,0.78560560315892003,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,2000,300,0,60,100,3100,0,20,400,600,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8750,"$8750 per person | $17500 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",2000,"$2000 per person | $4000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,500,null,500,"Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","$250.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$15.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"$15.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1]
["42690MA1390005-00","HMO Blue Select $3,000 Deductible","Silver","Standard Silver Off Exchange Plan",null,0.71528455006868497,"No","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,3000,1000,0,60,100,3500,0,20,1400,100,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9100,"$9100 per person | $18200 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",3000,"$3000 per person | $6000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,40,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"$750.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,175,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,175,null,"Not Applicable","Not Applicable",null,1]
["42690MA1390007-00","HMO Blue Select Saver $2,000","Silver","Standard Silver Off Exchange Plan",null,0.70399883887836301,"Yes","Yes","Yes","All specialists except OB/GYN providers ","No",1,null,2000,900,0,60,2000,2300,0,20,2000,300,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7150,"$7150 per person | $14300 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2000,"$4000 per person | $4000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Yes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"$250.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$175.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$175.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1]

{"sheet":"Benefits Package 10","index":19,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1350019","Preferred Blue PPO $1,500 Deductible","42690MA135","MAN002","MAS002","MAF007","Existing","PPO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Except emergency, out of network benefits","Yes","Except emergency, out of network benefits","Yes"]
["42690MA1350020","Preferred Blue PPO $2,500 Deductible","42690MA135","MAN002","MAS002","MAF007","Existing","PPO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Except emergency, out of network benefits","Yes","Except emergency, out of network benefits","Yes"]
["42690MA1350018","Preferred Blue PPO $4,500 Deductible","42690MA135","MAN002","MAS002","MAF015","Existing","PPO","Expanded Bronze","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Except emergency, out of network benefits","Yes","Except emergency, out of network benefits","Yes"]
[]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
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Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1350019-00","Preferred Blue PPO $1,500 Deductible","Silver","Standard Silver Off Exchange Plan",null,0.70319392022596605,"No","Yes","No",null,"No",1,null,1500,70,1100,60,900,2900,0,20,1500,600,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8750,"$8750 per person | $17500 per group",null,null,17500,"$17500 per person | $35000 per group","Not Applicable","per person not applicable | per group not applicable",1500,"$1500 per person | $3000 per group",0,null,null,null,4500,"$4500 per person | $9000 per group","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,0,"$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$350.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible",45,null,90,"Not Applicable",null,"Not Applicable",150,null,300,"Not Applicable",null,"Not Applicable",225,null,450,"Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable",0.5,null,"Not Applicable","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,"55.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$80.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible",225,null,450,"Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable",150,null,300,"Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible",150,null,300,"Not Applicable",null,"Not Applicable"]
["42690MA1350020-00","Preferred Blue PPO $2,500 Deductible","Silver","Standard Silver Off Exchange Plan",null,0.687908153664746,"No","Yes","No",null,"No",1,null,2500,70,1100,60,900,2900,0,20,2500,100,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8750,"$8750 per person | $17500 per group",null,null,17500,"$17500 per person | $35000 per group","Not Applicable","per person not applicable | per group not applicable",2500,"$2500 per person | $5000 per group",0,null,null,null,5500,"$5500 per person | $11000 per group","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,0,"$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$350.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible",45,null,90,"Not Applicable",null,"Not Applicable",150,null,300,"Not Applicable",null,"Not Applicable",225,null,450,"Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable",0.5,null,"Not Applicable","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,"55.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible",225,null,450,"Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable",150,null,300,"Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible",150,null,300,"Not Applicable",null,"Not Applicable"]
["42690MA1350018-00","Preferred Blue PPO $4,500 Deductible","Expanded Bronze","Standard Bronze Off Exchange Plan",null,0.64225168536254895,"No","Yes","No",null,"No",1,null,4500,10,800,60,900,3200,0,20,2800,10,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9100,"$9100 per person | $18200 per group",null,null,18200,"$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable",4500,"$4500 per person | $9000 per group",0,null,null,null,7500,"$7500 per person | $15000 per group","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,0,"$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$600.00 Copay after deductible",null,"$600.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible",45,null,90,"Not Applicable",null,"Not Applicable",175,null,350,"Not Applicable",null,"Not Applicable",225,null,450,"Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable",0.5,null,"Not Applicable","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,"55.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$100.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$200.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible",225,null,450,"Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable",175,null,350,"Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$100.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible",175,null,350,"Not Applicable",null,"Not Applicable"]

{"sheet":"Benefits Package 11","index":21,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1370005","Preferred Blue PPO Saver $2,000","42690MA137","MAN002","MAS002","MAF004","Existing","PPO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Except emergency, out of network benefits","Yes","Except emergency, out of network benefits","Yes"]
["42690MA1370007","Preferred Blue PPO Saver $3,000","42690MA137","MAN002","MAS002","MAF002","Existing","PPO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Except emergency, out of network benefits","Yes","Except emergency, out of network benefits","Yes"]
["42690MA1370009","Preferred Blue PPO Saver $4,500","42690MA137","MAN002","MAS002","MAF004","Existing","PPO","Silver","Not Applicable","Yes","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Except emergency, out of network benefits","Yes","Except emergency, out of network benefits","Yes"]
[]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
["HIOS Plan ID \n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","CSR Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1370005-00","Preferred Blue PPO Saver $2,000","Silver","Standard Silver Off Exchange Plan",null,0.701653412670878,"Yes","Yes","No",null,"No",1,null,2000,70,1100,60,2000,2300,0,20,2000,300,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7150,"$7150 per person | $14300 per group",null,null,14300,"$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2000,"$4000 per person | $4000 per group",0,null,null,null,5000,"$10000 per person | $10000 per group","Not Applicable","per person not applicable | per group not applicable","Yes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$350.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"$90.00 Copay after deductible","Not Applicable",null,"Not Applicable","$175.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable","$250.00 Copay after deductible",null,"$500.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"Not Applicable","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$450.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,0.2,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,"55.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$100.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$250.00 Copay after deductible",null,"$500.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$175.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$175.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable"]
["42690MA1370007-00","Preferred Blue PPO Saver $3,000","Silver","Standard Silver Off Exchange Plan",null,0.68832232884675504,"Yes","Yes","No",null,"No",1,null,3000,70,800,60,3000,1500,0,20,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7150,"$7150 per person | $14300 per group",null,null,14300,"$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3000,"$6000 per person | $6000 per group",0,null,null,null,6000,"$12000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","Yes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$250.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$400.00 Copay after deductible",null,"$400.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"$90.00 Copay after deductible","Not Applicable",null,"Not Applicable","$150.00 Copay after deductible",null,"$300.00 Copay after deductible","Not Applicable",null,"Not Applicable","$225.00 Copay after deductible",null,"$450.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"Not Applicable","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$450.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,0.2,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,"55.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$100.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$225.00 Copay after deductible",null,"$450.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$150.00 Copay after deductible",null,"$300.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$150.00 Copay after deductible",null,"$300.00 Copay after deductible","Not Applicable",null,"Not Applicable"]
["42690MA1370009-00","Preferred Blue PPO Saver $4,500","Silver","Standard Silver Off Exchange Plan",0.68049999999999999,0.67853732549526302,"Yes","Yes","No",null,"No",1,null,4500,10,800,60,4500,600,0,20,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,6800,"$6800 per person | $13600 per group",null,null,13600,"$13600 per person | $27200 per group","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,4500,"$9000 per person | $9000 per group",0,null,null,null,7500,"$15000 per person | $15000 per group","Not Applicable","per person not applicable | per group not applicable","Yes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$500.00 Copay after deductible",null,"$500.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$45.00 Copay after deductible",null,"$90.00 Copay after deductible","Not Applicable",null,"Not Applicable","$175.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable","$250.00 Copay after deductible",null,"$500.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"Not Applicable","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,0.2,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,"55.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$175.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"40.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$250.00 Copay after deductible",null,"$500.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$175.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","10.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","Not Applicable",null,0.2,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$175.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable"]

{"sheet":"Benefits Package 12","index":23,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1350008","Preferred Blue PPO $500 Deductible with HCCS","42690MA135","MAN002","MAS002","MAF007","Existing","PPO","Gold","Not Applicable","Yes","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Except emergency, out of network benefits","Yes","Except emergency, out of network benefits","Yes"]
["42690MA1350017","Preferred Blue PPO $3,000 Deductible with HCCS","42690MA135","MAN002","MAS002","MAF008","Existing","PPO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Except emergency, out of network benefits","Yes","Except emergency, out of network benefits","Yes"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
["HIOS Plan ID \n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","CSR Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of 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(Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1350008-00","Preferred Blue PPO $500 Deductible with HCCS","Gold","Standard Gold Off Exchange Plan",0.78029999999999999,0.76932998314350565,"No","Yes","No",null,"Yes",0.9,0.1,500,100,1100,60,100,3100,0,20,500,500,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8550,"$8550 per person | $17100 per group",8550,"$8550 per person | $17100 per group",17100,"$17100 per person | $34200 per group","Not Applicable","per person not applicable | per group not applicable",500,"$500 per person | $1000 per group",0,500,"$500 per person | $1000 per group",0,3500,"$3500 per person | $7000 per group","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,30,30,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",50,50,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",30,30,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$250.00 Copay after deductible","$1250.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",50,50,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$300.00 Copay after deductible","$300.00 Copay after deductible","$300.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","No Charge after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",30,30,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",30,30,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",45,45,90,"Not Applicable","Not Applicable","Not Applicable",150,150,300,"Not Applicable","Not Applicable","Not Applicable",225,225,450,"Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable",0.5,0.5,"Not Applicable","$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",50,50,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","40.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$250.00 Copay after deductible","$500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",50,50,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","35.00% Coinsurance after deductible","35.00% Coinsurance after deductible","55.00% Coinsurance after deductible","$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$25.00 Copay after deductible","$60.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$25.00 Copay after deductible","$125.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",50,50,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",50,50,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","40.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",50,50,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",50,50,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",50,50,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",225,225,450,"Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","No Charge","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",150,150,300,"Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","$45.00 Copay after deductible","$45.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",50,50,"Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$25.00 Copay after deductible","$60.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",150,150,300,"Not Applicable","Not Applicable","Not Applicable"]
["42690MA1350017-00","Preferred Blue PPO $3,000 Deductible with HCCS","Silver","Standard Silver Off Exchange Plan",null,0.68165434009139581,"No","Yes","No",null,"Yes",0.9,0.1,3000,200,800,60,900,2900,0,20,2800,10,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8750,"$8750 per person | $17500 per group",8750,"$8750 per person | $17500 per group",17500,"$17500 per person | $35000 per group","Not Applicable","per person not applicable | per group not applicable",3000,"$3000 per person | $7500 per group",0,3000,"$3000 per person | $7500 per group",0,6000,"$6000 per person | $13000 per group","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$40.00 Copay after deductible","$40.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$40.00 Copay after deductible","$40.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$500.00 Copay after deductible","$1500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$500.00 Copay after deductible","$500.00 Copay after deductible","$500.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","No Charge after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","$40.00 Copay after deductible","$40.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","$40.00 Copay after deductible","$40.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible",45,45,90,"Not Applicable","Not Applicable","Not Applicable",150,150,300,"Not Applicable","Not Applicable","Not Applicable",250,250,500,"Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable",0.5,0.5,"Not Applicable","$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","40.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$350.00 Copay after deductible","$750.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",1,"No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","35.00% Coinsurance after deductible","35.00% Coinsurance after deductible","55.00% Coinsurance after deductible","$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$45.00 Copay after deductible","$80.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$35.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$55.00 Copay after deductible","$155.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","40.00% Coinsurance after deductible","No Charge after deductible","No Charge after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",250,250,500,"Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","No Charge","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable",150,150,300,"Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","Not Applicable","10.00% Coinsurance after deductible","20.00% Coinsurance after deductible","20.00% Coinsurance after deductible","$45.00 Copay after deductible","$45.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","No Charge","No Charge","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$55.00 Copay after deductible","$55.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible","$35.00 Copay after deductible","$70.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable","20.00% Coinsurance after deductible",150,150,300,"Not Applicable","Not Applicable","Not Applicable"]

{"sheet":"Benefits Package 13","index":25,"n_rows":139,"n_cols":30,"rows_kept":139,"cut":false,"hidden":false,"merged":[[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[129,0,129,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",42690,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","MA",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["42690MA1590001","Advantage Blue Preferred $2,000 Deductible","42690MA159","MAN003","MAS003","MAF014","New","EPO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","Yes"]
["42690MA1590002","Advantage Blue Preferred $3,000 Deductible","42690MA159","MAN003","MAS003","MAF006","New","EPO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","Yes"]
["42690MA1590003","Advantage Blue Preferred Saver $3,000","42690MA159","MAN003","MAS003","MAF001","New","EPO","Silver","Not Applicable","No","Off the Exchange","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy",0.99860000000000004,null,null,"2024-01-01",null,"Yes","Emergency and Urgent Care Services only","Yes","Emergency and Urgent Care Services only","Yes"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Hospice services' means pain control and symptom relief and supportive and other care for a member who is terminally ill (the patient is expected to live twelve months or less).",null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Only covers services to diagnose and treat infertility if unable to conceive during one year, or has been diagnosed with cancer and is expected to become infertile after treatment, or is age 35 or older and has not been able to conceive for 6 months. ",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per 2 Years",null,null,"Not EHB","No","No"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,"In a Rehabilitation Hospital (60-day benefit limit per member per calendar year).",null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,"Benefit limit per member.",null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,"50% but no more than $350 per supply for Preferred Brand Specialty Drugs",null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60-visit benefit level per calendar year, but no benefit limit for speech therapy or when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care. ","Other Law/Regulation","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,"This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service.",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,"One breast pump per birth (rented or purchased).",null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years",null,"$2,000 for one hearing aid for each hearing impaired ear every 36 months for members of any age. ","Not EHB","No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"GYN exam limited to one exam per calendar year.",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,null,"Covered","Yes",12,"Visit(s) per Year",null,"This health plan covers outpatient acupuncture services when they are furnished for you by a covered provider who is licensed to furnish the covered service.","Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",150,"Dollars per Year",null,"Your health plan will reimburse up to $150 for participation in qualified weight loss program(s) each calendar year.","Not EHB","No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year",null,"1 exam(s) per calendar year with no cost-sharing.",null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"One pair of prescription eyeglasses (lenses and/or frames) once per calendar year or, in lieu of eyeglasses, prescription contact lenses once per calendar year; low vision supplies; and the measurement, fitting, and adjustments of covered vision supplies.",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"60 visits combined outpatient physical and occupational therapy.",null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Orthodontia – Child"]
["Major Dental Care – Child",null,"Yes","Not Covered",null,null,null,null,null,"Dental Only Plan Available"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"This health plan covers medically necessary gender affirming services for transgender and gender diverse members when gender identity differs from assigned sex at birth. ","Additional EHB Benefit","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Other Law/Regulation","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,null,"Additional EHB Benefit","No","No"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Routine Eye Exam (Adult)",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery",null,null,null,null,null,"Gender Affirming Care",null,null,null,null,null,"Clinical Trials",null,null,null,null,null,"Diabetes Care Management",null,null,null,null,null,"Off Label Prescription Drugs",null,null,null,null,null,"Congenital Anomaly, including Cleft Lip/Palate",null,null,null,null,null,"Early Intervention Services",null,null,null,null,null,"Nutrition/Formulas",null,null,null,null,null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,null,null,null,null,"Cardiac Rehabilitation",null,null,null,null,null,"Contraceptive Services",null,null,null,null,null,"Hormone Replacement Therapy (HRT)",null,null,null,null,null,"Human Leukocyte Antigen Testing",null,null,null,null,null,"Hypodermic Syringes or Needles "]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
["HIOS Plan ID \n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","CSR Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["42690MA1590001-00","Advantage Blue Preferred $2,000 Deductible","Silver","Standard Silver Off Exchange Plan",null,0.71244745126976206,"No","Yes","No",null,"No",1,null,2000,1100,0,60,100,4100,0,20,2000,400,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9100,"$9100 per person | $18200 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",2000,"$2000 per person | $4000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",2000,"$2000 per person | $4000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,"Not Applicable","Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"$1000.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,275,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$225.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,275,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1]
["42690MA1590002-00","Advantage Blue Preferred $3,000 Deductible","Silver","Standard Silver Off Exchange Plan",null,0.71046562330123497,"No","Yes","No",null,"No",1,null,3000,1100,0,60,100,3200,0,20,2300,100,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9100,"$9100 per person | $18200 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",3000,"$3000 per person | $6000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable",0,"$0 per person | $0 per group",3000,"$3000 per person | $6000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,45,"Not Applicable","Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"$750.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,45,null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$175.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,225,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$85.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,65,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,150,null,"Not Applicable","Not Applicable",null,1]
["42690MA1590003-00","Advantage Blue Preferred Saver $3,000","Silver","Standard Silver Off Exchange Plan",null,0.68820523793306898,"Yes","Yes","No",null,"No",1,null,3000,600,0,60,3000,1500,0,20,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7150,"$7150 per person | $14300 per group",null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",3000,"$3000 per person | $6000 per group",0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3000,"$6000 per person | $6000 per group",0,null,null,null,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable","Yes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"$35.00 Copay after deductible","Not Applicable","Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$350.00 Copay after deductible",null,"$350.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","Not Applicable",null,"Not Applicable","$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$35.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$45.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$225.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$400.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","35.00% Coinsurance after deductible",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$100.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$225.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$150.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1]

{"sheet":"DefaultBP","index":27,"n_rows":127,"n_cols":30,"rows_kept":127,"cut":false,"hidden":true,"merged":[[126,0,126,1],[5,23,5,24],[5,25,5,29],[57,10,57,11],[58,0,58,1],[59,0,59,1],[5,0,5,5],[60,0,60,1],[5,6,5,20],[5,21,5,22],[57,0,57,2],[57,3,57,9],[72,0,72,1],[61,0,61,1],[62,0,62,1],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[68,0,68,1],[69,0,69,1],[70,0,70,1],[71,0,71,1],[84,0,84,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[81,0,81,1],[82,0,82,1],[83,0,83,1],[96,0,96,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[93,0,93,1],[94,0,94,1],[95,0,95,1],[108,0,108,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[105,0,105,1],[106,0,106,1],[107,0,107,1],[120,0,120,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[117,0,117,1],[118,0,118,1],[119,0,119,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",null,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*",null,null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*",null,null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*",null,null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
[]
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[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
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[]
["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness"]
["Specialist Visit"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)"]
["Outpatient Surgery Physician/Surgical Services"]
["Hospice Services"]
["Routine Dental Services (Adult)"]
["Infertility Treatment"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)"]
["Urgent Care Centers or Facilities"]
["Home Health Care Services"]
["Emergency Room Services"]
["Emergency Transportation/Ambulance"]
["Inpatient Hospital Services (e.g., Hospital Stay)"]
["Inpatient Physician and Surgical Services"]
["Bariatric Surgery"]
["Cosmetic Surgery"]
["Skilled Nursing Facility"]
["Prenatal and Postnatal Care"]
["Delivery and All Inpatient Services for Maternity Care"]
["Mental/Behavioral Health Outpatient Services"]
["Mental/Behavioral Health Inpatient Services"]
["Substance Abuse Disorder Outpatient Services"]
["Substance Abuse Disorder Inpatient Services"]
["Generic Drugs"]
["Preferred Brand Drugs"]
["Non-Preferred Brand Drugs"]
["Specialty Drugs"]
["Outpatient Rehabilitation Services"]
["Habilitation Services"]
["Chiropractic Care"]
["Durable Medical Equipment"]
["Hearing Aids"]
["Imaging (CT/PET Scans, MRIs)"]
["Preventive Care/Screening/Immunization"]
["Routine Foot Care"]
["Acupuncture"]
["Weight Loss Programs"]
["Routine Eye Exam for Children"]
["Eye Glasses for Children"]
["Dental Check-Up for Children"]
["Rehabilitative Speech Therapy"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy"]
["Well Baby Visits and Care"]
["Laboratory Outpatient and Professional Services"]
["X-rays and Diagnostic Imaging"]
["Basic Dental Care – Child"]
["Orthodontia – Child"]
["Major Dental Care – Child"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited"]
["Transplant"]
["Accidental Dental"]
["Dialysis"]
["Allergy Testing"]
["Chemotherapy"]
["Radiation"]
["Diabetes Education"]
["Prosthetic Devices"]
["Infusion Therapy"]
["Treatment for Temporomandibular Joint Disorders"]
["Nutritional Counseling"]
["Reconstructive Surgery"]
["Gender Affirming Care"]

{"sheet":"DefaultCSV","index":28,"n_rows":3,"n_cols":707,"rows_kept":3,"cut":false,"hidden":true,"merged":[[0,701,0,706],[1,701,1,703],[1,704,1,706],[0,689,0,694],[1,689,1,691],[1,692,1,694],[0,695,0,700],[1,695,1,697],[1,698,1,700],[0,677,0,682],[1,677,1,679],[1,680,1,682],[0,683,0,688],[1,683,1,685],[1,686,1,688],[0,665,0,670],[1,665,1,667],[1,668,1,670],[0,671,0,676],[1,671,1,673],[1,674,1,676],[0,653,0,658],[1,653,1,655],[1,656,1,658],[0,659,0,664],[1,659,1,661],[1,662,1,664],[0,641,0,646],[1,641,1,643],[1,644,1,646],[0,647,0,652],[1,647,1,649],[1,650,1,652],[0,629,0,634],[1,629,1,631],[1,632,1,634],[0,635,0,640],[1,635,1,637],[1,638,1,640],[0,617,0,622],[1,617,1,619],[1,620,1,622],[0,623,0,628],[1,623,1,625],[1,626,1,628],[0,605,0,610],[1,605,1,607],[1,608,1,610],[0,611,0,616],[1,611,1,613],[1,614,1,616],[0,593,0,598],[1,593,1,595],[1,596,1,598],[0,599,0,604],[1,599,1,601],[1,602,1,604],[0,581,0,586],[1,581,1,583],[1,584,1,586],[0,587,0,592],[1,587,1,589],[1,590,1,592],[0,569,0,574],[1,569,1,571],[1,572,1,574],[0,575,0,580],[1,575,1,577],[1,578,1,580],[0,557,0,562],[1,557,1,559],[1,560,1,562],[0,563,0,568],[1,563,1,565],[1,566,1,568],[0,545,0,550],[1,545,1,547],[1,548,1,550],[0,551,0,556],[1,551,1,553],[1,554,1,556],[0,533,0,538],[1,533,1,535],[1,536,1,538],[0,539,0,544],[1,539,1,541],[1,542,1,544],[0,521,0,526],[1,521,1,523],[1,524,1,526],[0,527,0,532],[1,527,1,529],[1,530,1,532],[0,509,0,514],[1,509,1,511],[1,512,1,514],[0,515,0,520],[1,515,1,517],[1,518,1,520],[0,497,0,502],[1,497,1,499],[1,500,1,502],[0,503,0,508],[1,503,1,505],[1,506,1,508],[0,485,0,490],[1,485,1,487],[1,488,1,490],[0,491,0,496],[1,491,1,493],[1,494,1,496],[0,473,0,478],[1,473,1,475],[1,476,1,478],[0,479,0,484],[1,479,1,481],[1,482,1,484],[0,461,0,466],[1,461,1,463],[1,464,1,466],[0,467,0,472],[1,467,1,469],[1,470,1,472],[0,449,0,454],[1,449,1,451],[1,452,1,454],[0,455,0,460],[1,455,1,457],[1,458,1,460],[0,437,0,442],[1,437,1,439],[1,440,1,442],[0,443,0,448],[1,443,1,445],[1,446,1,448],[0,425,0,430],[1,425,1,427],[1,428,1,430],[0,431,0,436],[1,431,1,433],[1,434,1,436],[0,413,0,418],[1,413,1,415],[1,416,1,418],[0,419,0,424],[1,419,1,421],[1,422,1,424],[0,401,0,406],[1,401,1,403],[1,404,1,406],[0,407,0,412],[1,407,1,409],[1,410,1,412],[0,389,0,394],[1,389,1,391],[1,392,1,394],[0,395,0,400],[1,395,1,397],[1,398,1,400],[0,377,0,382],[1,377,1,379],[1,380,1,382],[0,383,0,388],[1,383,1,385],[1,386,1,388],[0,365,0,370],[1,365,1,367],[1,368,1,370],[0,371,0,376],[1,371,1,373],[1,374,1,376],[0,353,0,358],[1,353,1,355],[1,356,1,358],[0,359,0,364],[1,359,1,361],[1,362,1,364],[0,341,0,346],[1,341,1,343],[1,344,1,346],[0,347,0,352],[1,347,1,349],[1,350,1,352],[0,329,0,334],[1,329,1,331],[1,332,1,334],[0,335,0,340],[1,335,1,337],[1,338,1,340],[0,317,0,322],[1,317,1,319],[1,320,1,322],[0,323,0,328],[1,323,1,325],[1,326,1,328],[0,305,0,310],[1,305,1,307],[1,308,1,310],[0,311,0,316],[1,311,1,313],[1,314,1,316],[0,293,0,298],[1,293,1,295],[1,296,1,298],[0,299,0,304],[1,299,1,301],[1,302,1,304],[0,281,0,286],[1,281,1,283],[1,284,1,286],[0,287,0,292],[1,287,1,289],[1,290,1,292],[0,269,0,274],[1,269,1,271],[1,272,1,274],[0,275,0,280],[1,275,1,277],[1,278,1,280],[0,257,0,262],[1,257,1,259],[1,260,1,262],[0,263,0,268],[1,263,1,265],[1,266,1,268],[0,245,0,250],[1,245,1,247],[1,248,1,250],[0,251,0,256],[1,251,1,253],[1,254,1,256],[0,233,0,238],[1,233,1,235],[1,236,1,238],[0,239,0,244],[1,239,1,241],[1,242,1,244],[0,221,0,226],[1,221,1,223],[1,224,1,226],[0,227,0,232],[1,227,1,229],[1,230,1,232],[0,209,0,214],[1,209,1,211],[1,212,1,214],[0,215,0,220],[1,215,1,217],[1,218,1,220],[0,197,0,202],[1,197,1,199],[1,200,1,202],[0,203,0,208],[1,203,1,205],[1,206,1,208],[0,185,0,190],[1,185,1,187],[1,188,1,190],[0,191,0,196],[1,191,1,193],[1,194,1,196],[0,173,0,178],[1,173,1,175],[1,176,1,178],[0,179,0,184],[1,179,1,181],[1,182,1,184],[0,161,0,166],[1,161,1,163],[1,164,1,166],[0,167,0,172],[1,167,1,169],[1,170,1,172],[0,149,0,154],[1,149,1,151],[1,152,1,154],[0,155,0,160],[1,155,1,157],[1,158,1,160],[0,137,0,142],[1,137,1,139],[1,140,1,142],[0,143,0,148],[1,143,1,145],[1,146,1,148],[0,125,0,130],[1,125,1,127],[1,128,1,130],[0,131,0,136],[1,131,1,133],[1,134,1,136],[0,113,0,118],[1,113,1,115],[1,116,1,118],[0,119,0,124],[1,119,1,121],[1,122,1,124],[1,72,1,74],[1,75,1,76],[1,77,1,78],[1,49,1,51],[1,52,1,54],[1,55,1,56],[1,57,1,58],[1,59,1,61],[1,62,1,64],[1,0,1,12],[1,13,1,16],[1,17,1,20],[1,25,1,26],[1,27,1,28],[1,29,1,30],[1,31,1,32],[1,33,1,34],[1,35,1,36],[1,21,1,24],[0,105,0,112],[1,105,1,106],[1,107,1,108],[1,109,1,110],[1,111,1,112],[1,87,1,88],[0,89,0,96],[1,89,1,90],[1,91,1,92],[1,93,1,94],[1,95,1,96],[0,13,0,24],[0,82,0,85],[0,97,0,104],[1,97,1,98],[1,99,1,100],[1,101,1,102],[1,103,1,104],[0,79,0,81],[1,79,1,81],[1,37,1,38],[1,39,1,40],[1,41,1,42],[1,43,1,44],[1,45,1,46],[1,47,1,48],[0,69,0,78],[0,25,0,32],[0,33,0,40],[0,41,0,48],[0,49,0,58],[0,59,0,68],[1,65,1,66],[1,67,1,68],[1,69,1,71]]}
["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3"]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out 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["Individual","AK","Yes","Accidental Ingestion of a Controlled Drug","MAN001","CSV Code Name","Already Ran AVC","Data Modified After Running AVC","Modified Fields","MAF001","MAS001"]
["SHOP (Small Group)","AL",null,"Anesthetics","MAN002","Sheet3",true,false,null,"MAF002","MAS002"]
[null,"AR",null,"Applied Behavior Analysis Based Therapies","MAN003","Sheet6",true,false,null,"MAF003","MAS003"]
["Bronze","AZ",null,"Attention Deficit Disorder",null,"Sheet12",true,true,"K4,L4,K5,L5","MAF004"]
["Expanded Bronze","CA",null,"Autism Spectrum Disorders",null,"Sheet14",true,false,null,"MAF005"]
["Silver","CO",null,"Blood and Blood Services",null,"Sheet18",true,false,null,"MAF006"]
["Gold","CT",null,"Bone Marrow Testing",null,"Sheet10",true,false,null,"MAF007"]
["Platinum","DC",null,"Bone Marrow Transplant",null,"Sheet20",true,false,null,"MAF008"]
["Catastrophic","DE",null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,"Sheet22",true,false,null,"MAF009"]
[null,"FL",null,"Bones/Joints",null,"Sheet24",true,false,null,"MAF010"]
["Yes","GA",null,"Brain Injury",null,"Sheet26",true,false,null,"MAF011"]
["No","HI",null,"Breast Implant Removal",null,"Sheet28",true,false,null,"MAF012"]
[null,"IA",null,"Breast Reconstructive Surgery",null,"Sheet30",true,false,null,"MAF013"]
["Indemnity","ID",null,"Cancer Treatments",null,"Sheet16",true,false,null,"MAF014"]
["PPO","IL",null,"Cardiac Rehabilitation",null,null,null,null,null,"MAF015"]
["HMO","IN",null,"Clinical Trials",null,null,null,null,null,"MAF016"]
["POS","KS",null,"Cochlear Implants"]
["EPO","KY",null,"Congenital Anomaly, including Cleft Lip/Palate"]
[null,"LA",null,"Contraceptive Services"]
["Allows Adult and Child-Only","MA",null,"Coverage for Effects of Diethylstilbestrol"]
["Allows Adult-Only","MD",null,"Dental Anesthesia"]
["Allows Child-Only","ME",null,"Developmental Needs of Children & Youth with Cancer"]
[null,"MI",null,"Diabetes Care Management"]
["New","MN",null,"Domestic Violence Treatment"]
["Existing","MO",null,"Drug Infusion Administration"]
[null,"MS",null,"Early Intervention Services"]
["Yes","MT",null,"Eating Disorder Treatment"]
["No","NC",null,"Emegency Transportation/Ambulance"]
["Not Applicable","ND",null,"Experimental or Investigational Services"]
[null,"NE",null,"Family Therapy"]
[null,"NH",null,"Gastric Electrical Stimulation"]
["$X","NJ",null,"Heart Transplant"]
["Not Applicable","NM",null,"Hormone Replacement Therapy (HRT)"]
[null,"NV",null,"Human Leukocyte Antigen Testing"]
["On the Exchange","NY",null,"Hypodermic Syringes or Needles "]
["Off the Exchange","OH",null,"Infant Formulas"]
["Both","OK",null,"Inherited Metabolic Disorder - PKU"]
[null,"OR",null,"Mental Health Other"]
["Covered","PA",null,"Mental Health Parity"]
["Not Covered","RI",null,"Morbid Obesity Treatment"]
[null,"SC",null,"Multiple Sclerosis "]
["Standard Plan","SD",null,"Network Retail Pharmacy (60-90 Day Supply) Covered"]
["73% AV CSR Silver Plan Variation","TN",null,"Newborn Hearing Screening"]
["87% AV CSR Silver Plan Variation","TX",null,"Newborn Services Other"]
["94% AV CSR Silver Plan Variation","UT",null,"Nutrition/Formulas"]
["Zero Cost Sharing Plan Variation","VA",null,"Off Label Prescription Drugs"]
["Limited Cost Sharing Plan Variation","VT",null,"Oral Surgery"]
[null,"WA",null,"Organ Transplants"]
["Click here to select","WI",null,"Osteoporosis"]
[null,"WV",null,"Outpatient Contraceptive Services Including Sterilizations"]
["Not EHB","WY",null,"Oxygen"]
["Substituted",null,null,"Pediatric Services Other"]
["Substantially Equal",null,null,"Port-Wine Stain Removal"]
["Using Alternate Benchmark",null,null,"Post-Mastectomy Care"]
["Other Law/Regulation",null,null,"Prescription Drugs Other"]
["Additional EHB Benefit",null,null,"Prescription Drugs Other "]
["Dental Only Plan Available",null,null,"Rape and Incest Coverage"]
[null,null,null,"Rehabilitative Occupational Therapy"]
["No Charge",null,null,"Rehabilitative Physical Therapy"]
["No Charge after deductible",null,null,"Residential Treatment for Children with Emotional Disabilities"]
["$X",null,null,"Second Opinion"]
["$X Copay after deductible",null,null,"Second Opinions Related to Chemical Dependency and Mental Health"]
["$X Copay with deductible",null,null,"Second Surgical Opinion"]
["Not Applicable",null,null,"Services to Ventilator-Dependent Persons"]
[null,null,null,"Sickle Cell Anemia"]
["$X Copay per Stay",null,null,"Third Opinion"]
["$X Copay per Stay with deductible",null,null,"Transplant Donor Coverage"]
["$X Copay per Stay after deductible",null,null,"Transplant Surgery—Donor Charges"]
["$X Copay per Day",null,null,"Treatment of hemophilia"]
["$X Copay per Day with deductible",null,null,"Treatment of Lyme Disease"]
["$X Copay per Day after deductible",null,null,"Treatment of Medical Complications of Alcoholism"]
["No Charge",null,null,"Well Child Care"]
["No Charge after deductible",null,null,"Wigs"]
["Not Applicable",null,null,"Wilm's Tumor"]
[null,null,null,"Wound Care for Individuals with Epidermolysis Bullosa"]
["No Charge"]
["No Charge after deductible",null,null,"Abortion for Which Public Funding is Prohibited"]
["X%",null,null,"Acupuncture"]
["X% Coinsurance after deductible",null,null,"Allergy Testing"]
["Not Applicable",null,null,"Bariatric Surgery"]
[null,null,null,"Chemotherapy"]
["Asthma",null,null,"Chiropractic Care"]
["Heart Disease",null,null,"Cosmetic Surgery"]
["Depression",null,null,"Delivery and All Inpatient Services for Maternity Care"]
["Diabetes",null,null,"Diabetes Education"]
["High Blood Pressure & High Cholesterol",null,null,"Dialysis"]
["Low Back Pain",null,null,"Durable Medical Equipment"]
["Pain Management",null,null,"Emergency Room Services"]
["Pregnancy",null,null,"Emergency Transportation/Ambulance"]
["Weight Loss Programs",null,null,"Eye Glasses for Children"]
[null,null,null,"Habilitation Services"]
["Visit(s)",null,null,"Hearing Aids"]
["Dollars",null,null,"Home Health Care Services"]
["Exam(s)",null,null,"Hospice Services"]
["Days",null,null,"Imaging (CT/PET Scans, MRIs)"]
["Item(s)",null,null,"Infertility Treatment"]
["Months",null,null,"Infusion Therapy"]
["Treatment(s)",null,null,"Inpatient Hospital Services (e.g., Hospital Stay)"]
["Procedure(s)",null,null,"Inpatient Physician and Surgical Services"]
["Hours",null,null,"Laboratory Outpatient and Professional Services"]
["Admission(s)",null,null,"Long-Term/Custodial Nursing Home Care"]
[null,null,null,"Mental/Behavioral Health Inpatient Services"]
["Year",null,null,"Mental/Behavioral Health Outpatient Services"]
["Benefit Period",null,null,"Non-Emergency Care When Traveling Outside the U.S."]
["Lifetime",null,null,"Nutritional Counseling"]
["Month",null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)"]
["Episode",null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)"]
["Stay",null,null,"Outpatient Rehabilitation Services"]
["Transplant",null,null,"Outpatient Surgery Physician/Surgical Services"]
["6 Months",null,null,"Prenatal and Postnatal Care"]
["2 Years",null,null,"Preventive Care/Screening/Immunization"]
["3 Years",null,null,"Primary Care Visit to Treat an Injury or Illness"]
["Procedure",null,null,"Private-Duty Nursing"]
["Week",null,null,"Prosthetic Devices"]
["Admission",null,null,"Radiation"]
[null,null,null,"Reconstructive Surgery"]
["Guaranteed Rate ",null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy"]
[null,null,null,"Rehabilitative Speech Therapy"]
[null,null,null,"Routine Eye Exam (Adult)"]
["High",null,null,"Routine Eye Exam for Children"]
["Low",null,null,"Routine Foot Care"]
[null,null,null,"Skilled Nursing Facility"]
["$X Copay per Stay",null,null,"Specialist Visit"]
["$X Copay per Stay with deductible",null,null,"Substance Abuse Disorder Inpatient Services"]
["$X Copay per Stay after deductible",null,null,"Substance Abuse Disorder Outpatient Services"]
["$X Copay per Day",null,null,"Transplant"]
["$X Copay per Day with deductible",null,null,"Treatment for Temporomandibular Joint Disorders"]
["$X Copay per Day after deductible",null,null,"Urgent Care Centers or Facilities"]
["$X",null,null,"Weight Loss Programs"]
["$X Copay with deductible",null,null,"Well Baby Visits and Care"]
["$X Copay after deductible",null,null,"X-rays and Diagnostic Imaging"]
["No Charge"]
["No Charge after deductible",null,null,"Click to enter Family MOOP"]
["Not Applicable"]
[null,null,null,"Click to enter Family Deductible"]
["Not Applicable"]
["Design 1"]
["Design 2"]
["Design 3"]
["Design 4"]
["Design 5"]