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{"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":147,"n_cols":30,"rows_kept":147,"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],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[139,0,139,1],[140,0,140,1],[141,0,141,1],[142,0,142,1],[143,0,143,1],[144,0,144,1],[145,0,145,1],[146,0,146,1]]}
["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*",36046,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*"]
["36046MA0750146","Standard High Gold","36046MA075","MAN001","MAS001","MAF005","New","HMO","Gold","Not Applicable","Yes","Both","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs",0.99670000000000003,null,null,"2024-01-01","2024-12-31","No",null,"No",null,"No"]
["36046MA0750148","Standard Silver II","36046MA075","MAN001","MAS001","MAF001","New","HMO","Silver","Not Applicable","Yes","Both","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs",0.99670000000000003,null,null,"2024-01-01","2024-12-31","No",null,"No",null,"No"]
["36046MA0750177","Standard Silver","36046MA075","MAN001","MAS001","MAF001","New","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, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs",0.99670000000000003,null,null,"2024-01-01","2024-12-31","No",null,"No",null,"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","Yes"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Provided in a Hospice-Outpatient setting.",null,"No","Yes"]
["Routine Dental Services (Adult)",null,null,"Not Covered"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Infertility treatment provided in an office or Hospital-Outpatient setting",null,"No","Yes"]
["Long-Term/Custodial Nursing Home Care",null,null,"Not Covered"]
["Private-Duty Nursing",null,null,"Not Covered"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per Year",null,"For Members age 19 and older.","Not EHB","No","Yes"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Cosmetic Surgery",null,null,"Not Covered"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,null,null,"No","Yes"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,"Routine Prenatal and Postnatal Care are covered in full.",null,"No","Yes"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,"Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered.",null,null,"No","Yes"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.",null,"No","Yes"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.","Substantially Equal","No","Yes"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years","Excluded for Members age 22 and older.","$2,000 per hearing aid every 36 months, per each hearing impaired ear.",null,"No","Yes"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered",null,null,null,null,null,"Substantially Equal","No","Yes"]
["Routine Foot Care",null,null,"Covered",null,null,null,"Excluded for all diagnosis, except for the treatment of Diabetes.",null,"Not EHB","No","Yes"]
["Acupuncture",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Weight Loss Programs",null,"Yes","Covered","Yes",3,"Months per Year","All Weight Loss Programs are excluded, except for Weight Watchers",null,null,"No","Yes"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year","Excluded for Members age 19 and older.",null,null,"No","Yes"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"Each Dependent under the age of 19 is eligible for coverage every 12 months for either prescription eyeglass frames and lenses or prescription contact lenses",null,"No","Yes"]
["Dental Check-Up for Children",null,"Yes","Covered","Yes",2,"Exam(s) per Year","Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Visits are limited to 60 per year combined.",null,"No","Yes"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Basic Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Orthodontia – Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services","Not EHB","No","Yes"]
["Major Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services",null,"No","Yes"]
["Basic Dental Care – Adult",null,null,"Not Covered"]
["Orthodontia – Adult",null,null,"Not Covered"]
["Major Dental Care – Adult",null,null,"Not Covered"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,"Procedure performed in an office or Hospital-Outpatient setting","Not EHB","No","Yes"]
["Transplant",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Accidental Dental",null,null,"Covered",null,null,null,"Any treatment after 3 days is not covered.  All services are excluded, except for the following: Extraction of the teeth damaged in the injury when needed to avoid\ninfection, Reimplantation and stabilization of dislodged teeth, Repositioning and stabilization of partly dislodged teeth, Suturing and suture removal, Medication received from the provider",null,"Not EHB","No","Yes"]
["Dialysis",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Radiation",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,"No Dental Care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment.","Provided in a Surgery-Outpatient setting.",null,"No","Yes"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"Provided in a Hospital- Acute Inpatient setting.","Not EHB","No","Yes"]
["Clinical Trials",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,"Excluded for Members age 18 and older","Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Early Intervention Services",null,null,"Covered",null,null,null,"Excluded for Members ages 3 and older",null,"Not EHB","No","Yes"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Fitness Club Reimbursement",null,null,"Covered",null,null,null,"Excludes coverage for  fees or costs that you pay for country clubs, tennis clubs, social clubs (such as ski, riding or hiking clubs), gymnastics facilities, pool-only facilities, sports teams or leagues, spas, instructional dance studios and martial arts schools.","Coverage provided for the greater of 1 month membership or $300 at no charge.","Not EHB","No","Yes"]
["Childbirth Classes",null,null,"Covered",null,null,null,"In excess of 1 initial Childbirth Course or 1 refresher course per pregnancy will not be covered",null,"Not EHB","No","Yes"]
["Wigs",null,null,"Covered","Yes",1,"Item(s) per Year   ","All types of wigs are excluded, except for a synthetic monofilament wig",null,"Not EHB","No","Yes"]
["Inpatient Rehabilitation Services",null,null,"Covered","Yes",60,"Days per Year",null,null,"Not EHB","No","Yes"]
["Retail Health Clinics",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Low Protein Foods",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Inherited Metabolic Disorders - PKU",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Minor Dental Care - Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 20% coinsurance of covered dental services","Not EHB","No","Yes"]

{"sheet":"Cost Share Variances 1","index":2,"n_rows":15,"n_cols":599,"rows_kept":15,"cut":false,"hidden":false,"merged":[[0,69,0,78],[0,79,0,81],[0,82,0,85],[0,89,0,96],[0,97,0,104],[0,105,0,112],[0,13,0,24],[0,25,0,32],[0,33,0,40],[0,41,0,48],[0,49,0,58],[0,59,0,68],[1,29,1,30],[1,31,1,32],[1,33,1,34],[1,35,1,36],[1,37,1,38],[1,39,1,40],[1,0,1,12],[1,13,1,16],[1,17,1,20],[1,21,1,24],[1,25,1,26],[1,27,1,28],[1,55,1,56],[1,57,1,58],[1,59,1,61],[1,62,1,64],[1,65,1,66],[1,67,1,68],[1,41,1,42],[1,43,1,44],[1,45,1,46],[1,47,1,48],[1,49,1,51],[1,52,1,54],[1,89,1,90],[1,91,1,92],[1,93,1,94],[1,95,1,96],[1,97,1,98],[1,99,1,100],[1,69,1,71],[1,72,1,74],[1,75,1,76],[1,77,1,78],[1,79,1,81],[1,87,1,88],[0,113,0,118],[1,113,1,115],[1,116,1,118],[0,119,0,124],[1,119,1,121],[1,122,1,124],[1,101,1,102],[1,103,1,104],[1,105,1,106],[1,107,1,108],[1,109,1,110],[1,111,1,112],[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],[0,161,0,166],[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],[0,185,0,190],[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],[0,209,0,214],[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],[0,233,0,238],[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],[0,257,0,262],[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],[0,281,0,286],[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],[0,305,0,310],[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],[0,329,0,334],[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],[0,353,0,358],[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],[0,377,0,382],[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],[0,401,0,406],[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],[0,425,0,430],[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],[0,449,0,454],[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],[0,473,0,478],[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],[0,497,0,502],[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],[0,521,0,526],[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],[0,545,0,550],[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],[0,569,0,574],[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],[0,593,0,598],[1,593,1,595],[1,596,1,598],[0,581,0,586],[1,581,1,583],[1,584,1,586],[0,587,0,592],[1,587,1,589],[1,590,1,592]]}
["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,"Routine Foot Care",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,"Dental Check-Up 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,"Basic Dental Care – Child",null,null,null,null,null,"Orthodontia – Child",null,null,null,null,null,"Major Dental Care – Child",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Accidental Dental",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 ",null,null,null,null,null,"Fitness Club Reimbursement",null,null,null,null,null,"Childbirth Classes",null,null,null,null,null,"Wigs",null,null,null,null,null,"Inpatient Rehabilitation Services",null,null,null,null,null,"Retail Health Clinics",null,null,null,null,null,"Low Protein Foods",null,null,null,null,null,"Inherited Metabolic Disorders - PKU",null,null,null,null,null,"Minor Dental Care - Child"]
["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",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",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 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["36046MA0750146-00","Standard High Gold","Gold","Standard Gold Off Exchange Plan",0.81659999999999999,0.81620473034923002,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,1300,0,0,0,1800,0,0,0,800,50,0,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",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",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,1,55,null,"Not Applicable","Not Applicable",null,1,30,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","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,30,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,350,null,350,"Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","No Charge",null,"No Charge","$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,90,null,"Not Applicable","Not Applicable",null,1,90,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,55,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",30,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,55,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,55,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,30,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,90,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,750,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,30,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable",0.2,null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750146-01","Standard High Gold","Gold","Standard Gold On Exchange Plan",0.81659999999999999,0.81620473034923002,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,1300,0,0,0,1800,0,0,0,800,50,0,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",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",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,1,55,null,"Not Applicable","Not Applicable",null,1,30,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","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,30,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,350,null,350,"Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","No Charge",null,"No Charge","$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,90,null,"Not Applicable","Not Applicable",null,1,90,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,55,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",30,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,55,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,55,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,30,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,90,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,750,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,30,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable",0.2,null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750146-02","HMO","Gold","Zero Cost Sharing Plan Variation",1,1,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,0,0,0,0,0,0,0,0,0,0,0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group","No",null,null,null,null,null,null,null,null,null,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
["36046MA0750146-03","Standard High Gold","Gold","Limited Cost Sharing Plan Variation",0.81659999999999999,0.81620473034923002,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,1300,0,0,0,1800,0,0,0,800,50,0,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",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",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,1,55,null,"Not Applicable","Not Applicable",null,1,30,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","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,30,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,350,null,350,"Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","No Charge",null,"No Charge","$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,90,null,"Not Applicable","Not Applicable",null,1,90,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,55,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",30,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,55,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,75,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,55,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,30,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,90,null,"Not Applicable","Not Applicable",null,1,750,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,750,null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,30,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable",0.2,null,1,750,null,"Not Applicable","Not Applicable",null,1,30,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750148-00","Standard Silver II","Silver","Standard Silver Off Exchange Plan",0.71919999999999995,0.71819852385274996,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,2000,1400,0,0,1100,900,0,0,2000,400,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9450,"$9450 per person | $18900 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,"$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,null,"Not Applicable","Not Applicable",null,1,60,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","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,25,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"$5.00 Copay 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","No Charge after deductible",null,"No Charge after deductible","$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","No Charge",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,1,30,null,"Not Applicable","Not Applicable",null,1,55,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,1,60,null,"Not Applicable","Not Applicable",null,1,60,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,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,60,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",25,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,60,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$25.00 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","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$25.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge after deductible",null,1,25,null,"Not Applicable","Not Applicable",null,1,25,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,1,25,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$25.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750148-01","Standard Silver II","Silver","Standard Silver On Exchange Plan",0.71919999999999995,0.71819852385274996,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,2000,1400,0,0,1100,900,0,0,2000,400,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9450,"$9450 per person | $18900 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,"$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,null,"Not Applicable","Not Applicable",null,1,60,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","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,25,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"$5.00 Copay 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","No Charge after deductible",null,"No Charge after deductible","$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","No Charge",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,1,30,null,"Not Applicable","Not Applicable",null,1,55,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,1,60,null,"Not Applicable","Not Applicable",null,1,60,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,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,60,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",25,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,60,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$25.00 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","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$25.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge after deductible",null,1,25,null,"Not Applicable","Not Applicable",null,1,25,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,1,25,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$25.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750148-02","HMO","Silver","Zero Cost Sharing Plan Variation",1,1,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,0,0,0,0,0,0,0,0,0,0,0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group","No",null,null,null,null,null,null,null,null,null,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
["36046MA0750148-03","Standard Silver II","Silver","Limited Cost Sharing Plan Variation",0.71919999999999995,0.71819852385274996,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,2000,1400,0,0,1100,900,0,0,2000,400,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9450,"$9450 per person | $18900 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,"$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,null,"Not Applicable","Not Applicable",null,1,60,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","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,25,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"$5.00 Copay 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","No Charge after deductible",null,"No Charge after deductible","$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","No Charge",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,1,30,null,"Not Applicable","Not Applicable",null,1,55,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,1,60,null,"Not Applicable","Not Applicable",null,1,60,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,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,60,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",25,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,60,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$25.00 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","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$25.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge after deductible",null,1,25,null,"Not Applicable","Not Applicable",null,1,25,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,1,25,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$25.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750148-04","Standard Connector Care 3","Silver","73% AV Level Silver Plan",0.73929999999999996,0.93067288778814095,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,0,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2250,"$2250 per person | $4500 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,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","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",null,"Not Applicable","Not Applicable",null,1,22,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,125,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,22,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,100,null,100,"Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","No Charge",null,"No Charge","$250.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$250.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,12.5,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,22,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,22,null,"Not Applicable","Not Applicable",null,1,22,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,20,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,22,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,250,null,"Not Applicable","Not Applicable",null,1,250,null,"Not Applicable","Not Applicable",null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,250,null,"Not Applicable","Not Applicable",null,1,22,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",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,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","No Charge",null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750148-05","Standard Connector Care 2","Silver","87% AV Level Silver Plan",0.87880000000000003,0.96060032197179102,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,100,0,0,0,700,0,0,0,100,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1250,"$1250 per person | $2500 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,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","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",null,"Not Applicable","Not Applicable",null,1,18,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","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,18,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,50,null,50,"Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","No Charge",null,"No Charge","$50.00 Copay per Stay",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","No Charge",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,10,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,10,null,"Not Applicable","Not Applicable",null,1,10,null,"Not Applicable","Not Applicable",null,1,18,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1,30,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,18,null,"Not Applicable","Not Applicable",null,1,18,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,10,null,"Not Applicable","Not Applicable",null,1,10,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,18,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",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,1,50,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","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,50,null,"Not Applicable","Not Applicable",null,1,18,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","No Charge",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750148-06","Standard Connector Care 1","Silver","94% AV Level Silver Plan",0.94850000000000001,0.997499150643407,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,300,0,0,0,700,0,0,0,200,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,250,"$250 per person | $500 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,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","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",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",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",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",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",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",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,1,null,"Not Applicable","Not Applicable",null,1,3.65,null,"Not Applicable","Not Applicable",null,1,3.65,null,"Not Applicable","Not Applicable",null,1,3.65,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,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",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",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,3.65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,3.65,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","No Charge",null,1]
["36046MA0750177-00","Standard Silver","Silver","Standard Silver Off Exchange Plan",0.71919999999999995,0.71819852385274996,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,2000,1400,0,0,1100,900,0,0,2000,400,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9450,"$9450 per person | $18900 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,"$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,null,"Not Applicable","Not Applicable",null,1,60,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","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,25,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge after deductible",null,"No Charge after deductible","$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","No Charge",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,1,30,null,"Not Applicable","Not Applicable",null,1,55,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,1,60,null,"Not Applicable","Not Applicable",null,1,60,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,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$350.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,60,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",25,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,60,null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$25.00 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","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$25.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge after deductible",null,1,25,null,"Not Applicable","Not Applicable",null,1,25,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,1,25,null,"Not Applicable","Not Applicable",null,1,"$75.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,60,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,"$25.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,55,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]

{"sheet":"Benefits Package 2","index":3,"n_rows":147,"n_cols":30,"rows_kept":147,"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],[141,0,141,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[139,0,139,1],[140,0,140,1],[142,0,142,1],[143,0,143,1],[144,0,144,1],[145,0,145,1],[146,0,146,1]]}
["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*",36046,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*"]
["36046MA0750145","Standard Platinum - Flex","36046MA075","MAN002","MAS001","MAF006","New","HMO","Platinum","Not Applicable","Yes","Both","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs",0.99670000000000003,null,null,"2024-01-01","2024-12-31","No",null,"No",null,"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","Yes"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,"Flex Providers will have a $100 Copayment per visit. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Provided in a Hospice-Outpatient setting.",null,"No","Yes"]
["Routine Dental Services (Adult)",null,null,"Not Covered"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Infertility treatment provided in an office or Hospital-Outpatient setting",null,"No","Yes"]
["Long-Term/Custodial Nursing Home Care",null,null,"Not Covered"]
["Private-Duty Nursing",null,null,"Not Covered"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per Year",null,"For Members age 19 and older.","Not EHB","No","Yes"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Cosmetic Surgery",null,null,"Not Covered"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,null,null,"No","Yes"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,"Routine Prenatal and Postnatal Care are covered in full.",null,"No","Yes"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,"Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered.",null,null,"No","Yes"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.",null,"No","Yes"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.","Substantially Equal","No","Yes"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years","Excluded for Members age 22 and older.","$2,000 per hearing aid every 36 months, per each hearing impaired ear.",null,"No","Yes"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered",null,null,null,null,null,"Substantially Equal","No","Yes"]
["Routine Foot Care",null,null,"Covered",null,null,null,"Excluded for all diagnosis, except for the treatment of Diabetes.",null,"Not EHB","No","Yes"]
["Acupuncture",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Weight Loss Programs",null,"Yes","Covered","Yes",3,"Months per Year","All Weight Loss Programs are excluded, except for Weight Watchers",null,null,"No","Yes"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year","Excluded for Members age 19 and older.",null,null,"No","Yes"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"Each Dependent under the age of 19 is eligible for coverage every 12 months for either prescription eyeglass frames and lenses or prescription contact lenses",null,"No","Yes"]
["Dental Check-Up for Children",null,"Yes","Covered","Yes",2,"Exam(s) per Year","Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Visits are limited to 60 per year combined.",null,"No","Yes"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Basic Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Orthodontia – Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services","Not EHB","No","Yes"]
["Major Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services",null,"No","Yes"]
["Basic Dental Care – Adult",null,null,"Not Covered"]
["Orthodontia – Adult",null,null,"Not Covered"]
["Major Dental Care – Adult",null,null,"Not Covered"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,"Procedure performed in an office or Hospital-Outpatient setting","Not EHB","No","Yes"]
["Transplant",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Accidental Dental",null,null,"Covered",null,null,null,"Any treatment after 3 days is not covered.  All services are excluded, except for the following: Extraction of the teeth damaged in the injury when needed to avoid infection, Reimplantation and stabilization of dislodged teeth, Repositioning and stabilization of partly dislodged teeth, Suturing and suture removal, Medication received from the provider",null,"Not EHB","No","Yes"]
["Dialysis",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Radiation",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,"No Dental Care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment.","Provided in a Surgery-Outpatient setting.\nFlex Providers will have a $100 Copayment per visit. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"Provided in a Hospital- Acute Inpatient setting.","Not EHB","No","Yes"]
["Clinical Trials",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,"Excluded for Members age 18 and older","Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Early Intervention Services",null,null,"Covered",null,null,null,"Excluded for Members age 3 and older",null,"Not EHB","No","Yes"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Fitness Club Reimbursement",null,null,"Covered",null,null,null,"Excludes coverage for  fees or costs that you pay for country clubs, tennis clubs, social clubs (such as ski, riding or hiking clubs), gymnastics facilities, pool-only facilities, sports teams or leagues, spas, instructional dance studios and martial arts schools.","Coverage provided for the greater of 1 month membership or $300 at no charge.","Not EHB","No","Yes"]
["Childbirth Classes",null,null,"Covered",null,null,null,"In excess of 1 initial Childbirth Course or 1 refresher course per pregnancy will not be covered",null,"Not EHB","No","Yes"]
["Wigs",null,null,"Covered","Yes",1,"Item(s) per Year   ","All types of wigs are excluded, except for a synthetic monofilament wig",null,"Not EHB","No","Yes"]
["Inpatient Rehabilitation Services",null,null,"Covered","Yes",60,"Days per Year",null,null,"Not EHB","No","Yes"]
["Retail Health Clinics",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Low Protein Foods",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Inherited Metabolic Disorders - PKU",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Minor Dental Care - Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 20% coinsurance of covered dental services","Not EHB","No","Yes"]

{"sheet":"Cost Share Variances 2","index":4,"n_rows":7,"n_cols":599,"rows_kept":7,"cut":false,"hidden":false,"merged":[[0,69,0,78],[0,79,0,81],[0,82,0,85],[0,89,0,96],[0,97,0,104],[0,105,0,112],[0,13,0,24],[0,25,0,32],[0,33,0,40],[0,41,0,48],[0,49,0,58],[0,59,0,68],[1,29,1,30],[1,31,1,32],[1,33,1,34],[1,35,1,36],[1,37,1,38],[1,39,1,40],[1,0,1,12],[1,13,1,16],[1,17,1,20],[1,21,1,24],[1,25,1,26],[1,27,1,28],[1,55,1,56],[1,57,1,58],[1,59,1,61],[1,62,1,64],[1,65,1,66],[1,67,1,68],[1,41,1,42],[1,43,1,44],[1,45,1,46],[1,47,1,48],[1,49,1,51],[1,52,1,54],[1,89,1,90],[1,91,1,92],[1,93,1,94],[1,95,1,96],[1,97,1,98],[1,99,1,100],[1,69,1,71],[1,72,1,74],[1,75,1,76],[1,77,1,78],[1,79,1,81],[1,87,1,88],[0,113,0,118],[1,113,1,115],[1,116,1,118],[0,119,0,124],[1,119,1,121],[1,122,1,124],[1,101,1,102],[1,103,1,104],[1,105,1,106],[1,107,1,108],[1,109,1,110],[1,111,1,112],[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],[0,161,0,166],[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],[0,185,0,190],[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],[0,209,0,214],[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],[0,233,0,238],[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],[0,257,0,262],[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],[0,281,0,286],[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],[0,305,0,310],[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],[0,329,0,334],[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],[0,353,0,358],[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],[0,377,0,382],[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],[0,401,0,406],[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],[0,425,0,430],[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],[0,449,0,454],[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],[0,473,0,478],[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],[0,497,0,502],[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],[0,521,0,526],[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],[0,545,0,550],[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],[0,569,0,574],[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],[0,593,0,598],[1,593,1,595],[1,596,1,598],[0,581,0,586],[1,581,1,583],[1,584,1,586],[0,587,0,592],[1,587,1,589],[1,590,1,592]]}
["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,"Routine Foot Care",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,"Dental Check-Up 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,"Basic Dental Care – Child",null,null,null,null,null,"Orthodontia – Child",null,null,null,null,null,"Major Dental Care – Child",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Accidental Dental",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 ",null,null,null,null,null,"Fitness Club Reimbursement",null,null,null,null,null,"Childbirth Classes",null,null,null,null,null,"Wigs",null,null,null,null,null,"Inpatient Rehabilitation Services",null,null,null,null,null,"Retail Health Clinics",null,null,null,null,null,"Low Protein Foods",null,null,null,null,null,"Inherited Metabolic Disorders - PKU",null,null,null,null,null,"Minor Dental Care - Child"]
["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",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",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 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["36046MA0750145-00","Standard Platinum - Flex","Platinum","Standard Platinum Off Exchange Plan",0.90539999999999998,null,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,600,0,0,0,1300,0,0,0,300,50,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3000,"$3000 per person | $6000 per group",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",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,20,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,20,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,150,null,150,"Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","No Charge",null,"No Charge","$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,10,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,150,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",20,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,40,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,250,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,20,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable",0.2,null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750145-01","Standard Platinum - Flex","Platinum","Standard Platinum On Exchange Plan",0.90539999999999998,null,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,600,0,0,0,1300,0,0,0,300,50,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3000,"$3000 per person | $6000 per group",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",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,20,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,20,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,150,null,150,"Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","No Charge",null,"No Charge","$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,10,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,150,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",20,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,40,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,250,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,20,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable",0.2,null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750145-02","HMO","Platinum","Zero Cost Sharing Plan Variation",1,null,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,0,0,0,0,0,0,0,0,0,0,0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group","No",null,null,null,null,null,null,null,null,null,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
["36046MA0750145-03","Standard Platinum - Flex","Platinum","Limited Cost Sharing Plan Variation",0.90539999999999998,null,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,600,0,0,0,1300,0,0,0,300,50,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3000,"$3000 per person | $6000 per group",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",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,20,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,250,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,20,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,150,null,150,"Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","No Charge",null,"No Charge","$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay per Stay",null,"Not Applicable","Not Applicable",null,1,10,null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,150,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",20,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,40,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,40,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,250,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,500,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,500,null,"Not Applicable","Not Applicable",null,1,40,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,20,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable",0.2,null,1,500,null,"Not Applicable","Not Applicable",null,1,20,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]

{"sheet":"Benefits Package 3","index":5,"n_rows":147,"n_cols":30,"rows_kept":147,"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],[141,0,141,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[139,0,139,1],[140,0,140,1],[142,0,142,1],[143,0,143,1],[144,0,144,1],[145,0,145,1],[146,0,146,1]]}
["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*",36046,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*"]
["36046MA0750149","HMO 2000 Low - Flex","36046MA075","MAN002","MAS001","MAF003","New","HMO","Gold","Not Applicable","Yes","Both","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs",0.99670000000000003,null,null,"2024-01-01","2024-12-31","No",null,"No",null,"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","Yes"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,"Flex Providers will have a $250 Copayment per visit. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Provided in a Hospice-Outpatient setting.",null,"No","Yes"]
["Routine Dental Services (Adult)",null,null,"Not Covered"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Infertility treatment provided in an office or Hospital-Outpatient setting",null,"No","Yes"]
["Long-Term/Custodial Nursing Home Care",null,null,"Not Covered"]
["Private-Duty Nursing",null,null,"Not Covered"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per Year",null,"For Members age 19 and older.","Not EHB","No","Yes"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Cosmetic Surgery",null,null,"Not Covered"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,null,null,"No","Yes"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,"Routine Prenatal and Postnatal Care are covered in full.",null,"No","Yes"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,"Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered.",null,null,"No","Yes"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.",null,"No","Yes"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.","Substantially Equal","No","Yes"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years","Excluded for Members age 22 and older.","$2,000 per hearing aid every 36 months, per each hearing impaired ear.",null,"No","Yes"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered",null,null,null,null,null,"Substantially Equal","No","Yes"]
["Routine Foot Care",null,null,"Covered",null,null,null,"Excluded for all diagnosis, except for the treatment of Diabetes.",null,"Not EHB","No","Yes"]
["Acupuncture",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Weight Loss Programs",null,"Yes","Covered","Yes",3,"Months per Year","All Weight Loss Programs are excluded, except for Weight Watchers",null,null,"No","Yes"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year","Excluded for Members age 19 and older.",null,null,"No","Yes"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"Each Dependent under the age of 19 is eligible for coverage every 12 months for either prescription eyeglass frames and lenses or prescription contact lenses",null,"No","Yes"]
["Dental Check-Up for Children",null,"Yes","Covered","Yes",2,"Exam(s) per Year","Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Visits are limited to 60 per year combined.",null,"No","Yes"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,"Flex Providers will have a $20 Copayment per visit. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Basic Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Orthodontia – Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services","Not EHB","No","Yes"]
["Major Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services",null,"No","Yes"]
["Basic Dental Care – Adult",null,null,"Not Covered"]
["Orthodontia – Adult",null,null,"Not Covered"]
["Major Dental Care – Adult",null,null,"Not Covered"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,"Procedure performed in an office or Hospital-Outpatient setting","Not EHB","No","Yes"]
["Transplant",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Accidental Dental",null,null,"Covered",null,null,null,"Any treatment after 3 days is not covered.  All services are excluded, except for the following: Extraction of the teeth damaged in the injury when needed to avoid infection, Reimplantation and stabilization of dislodged teeth, Repositioning and stabilization of partly dislodged teeth, Suturing and suture removal, Medication received from the provider",null,"Not EHB","No","Yes"]
["Dialysis",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Radiation",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,"No Dental Care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment.","Provided in a Surgery-Outpatient setting.\nFlex Providers will have a $250 Copayment per visit. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"Provided in a Hospital- Acute Inpatient setting.","Not EHB","No","Yes"]
["Clinical Trials",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,"Excluded for Members age 18 and older","Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Early Intervention Services",null,null,"Covered",null,null,null,"Excluded for Members age 3 and older",null,"Not EHB","No","Yes"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Fitness Club Reimbursement",null,null,"Covered",null,null,null,"Excludes coverage for  fees or costs that you pay for country clubs, tennis clubs, social clubs (such as ski, riding or hiking clubs), gymnastics facilities, pool-only facilities, sports teams or leagues, spas, instructional dance studios and martial arts schools.","Coverage provided for the greater of 1 month membership or $300 at no charge.","Not EHB","No","Yes"]
["Childbirth Classes",null,null,"Covered",null,null,null,"In excess of 1 initial Childbirth Course or 1 refresher course per pregnancy will not be covered",null,"Not EHB","No","Yes"]
["Wigs",null,null,"Covered","Yes",1,"Item(s) per Year   ","All types of wigs are excluded, except for a synthetic monofilament wig",null,"Not EHB","No","Yes"]
["Inpatient Rehabilitation Services",null,null,"Covered","Yes",60,"Days per Year",null,null,"Not EHB","No","Yes"]
["Retail Health Clinics",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Low Protein Foods",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Inherited Metabolic Disorders - PKU",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Minor Dental Care - Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 20% coinsurance of covered dental services","Not EHB","No","Yes"]

{"sheet":"Cost Share Variances 3","index":6,"n_rows":7,"n_cols":599,"rows_kept":7,"cut":false,"hidden":false,"merged":[[0,69,0,78],[0,79,0,81],[0,82,0,85],[0,89,0,96],[0,97,0,104],[0,105,0,112],[0,13,0,24],[0,25,0,32],[0,33,0,40],[0,41,0,48],[0,49,0,58],[0,59,0,68],[1,29,1,30],[1,31,1,32],[1,33,1,34],[1,35,1,36],[1,37,1,38],[1,39,1,40],[1,0,1,12],[1,13,1,16],[1,17,1,20],[1,21,1,24],[1,25,1,26],[1,27,1,28],[1,55,1,56],[1,57,1,58],[1,59,1,61],[1,62,1,64],[1,65,1,66],[1,67,1,68],[1,41,1,42],[1,43,1,44],[1,45,1,46],[1,47,1,48],[1,49,1,51],[1,52,1,54],[1,89,1,90],[1,91,1,92],[1,93,1,94],[1,95,1,96],[1,97,1,98],[1,99,1,100],[1,69,1,71],[1,72,1,74],[1,75,1,76],[1,77,1,78],[1,79,1,81],[1,87,1,88],[0,113,0,118],[1,113,1,115],[1,116,1,118],[0,119,0,124],[1,119,1,121],[1,122,1,124],[1,101,1,102],[1,103,1,104],[1,105,1,106],[1,107,1,108],[1,109,1,110],[1,111,1,112],[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],[0,161,0,166],[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],[0,185,0,190],[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],[0,209,0,214],[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],[0,233,0,238],[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],[0,257,0,262],[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],[0,281,0,286],[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],[0,305,0,310],[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],[0,329,0,334],[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],[0,353,0,358],[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],[0,377,0,382],[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],[0,401,0,406],[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],[0,425,0,430],[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],[0,449,0,454],[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],[0,473,0,478],[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],[0,497,0,502],[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],[0,521,0,526],[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],[0,545,0,550],[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],[0,569,0,574],[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],[0,593,0,598],[1,593,1,595],[1,596,1,598],[0,581,0,586],[1,581,1,583],[1,584,1,586],[0,587,0,592],[1,587,1,589],[1,590,1,592]]}
["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,"Routine Foot Care",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,"Dental Check-Up 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,"Basic Dental Care – Child",null,null,null,null,null,"Orthodontia – Child",null,null,null,null,null,"Major Dental Care – Child",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Accidental Dental",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 ",null,null,null,null,null,"Fitness Club Reimbursement",null,null,null,null,null,"Childbirth Classes",null,null,null,null,null,"Wigs",null,null,null,null,null,"Inpatient Rehabilitation Services",null,null,null,null,null,"Retail Health Clinics",null,null,null,null,null,"Low Protein Foods",null,null,null,null,null,"Inherited Metabolic Disorders - PKU",null,null,null,null,null,"Minor Dental Care - Child"]
["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",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",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","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["36046MA0750149-00","HMO 2000 Low - Flex","Gold","Standard Gold Off Exchange Plan",0.78069999999999995,null,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,2000,1100,0,0,1100,800,0,0,2000,400,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,5450,"$5450 per person | $10900 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",250,"$250 per person | $500 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,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,25,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$300.00 Copay after deductible",null,"$300.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge",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,1,30,null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$125.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$125.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$300.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",25,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",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","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge after deductible",null,1,"$500.00 Copay after deductible",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,"$750.00 Copay after deductible",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,"$125.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,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,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750149-01","HMO 2000 Low - Flex","Gold","Standard Gold On Exchange Plan",0.78069999999999995,null,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,2000,1100,0,0,1100,800,0,0,2000,400,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,5450,"$5450 per person | $10900 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",250,"$250 per person | $500 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,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,25,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$300.00 Copay after deductible",null,"$300.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge",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,1,30,null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$125.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$125.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$300.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",25,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",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","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge after deductible",null,1,"$500.00 Copay after deductible",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,"$750.00 Copay after deductible",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,"$125.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,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,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750149-02","HMO","Gold","Zero Cost Sharing Plan Variation",1,null,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,0,0,0,0,0,0,0,0,0,0,0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group","No",null,null,null,null,null,null,null,null,null,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
["36046MA0750149-03","HMO 2000 Low - Flex","Gold","Limited Cost Sharing Plan Variation",0.78069999999999995,null,"No","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,2000,1100,0,0,1100,800,0,0,2000,400,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,5450,"$5450 per person | $10900 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",250,"$250 per person | $500 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,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,25,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$300.00 Copay after deductible",null,"$300.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge",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,1,30,null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$125.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$125.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$300.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge",25,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,50,null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",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","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge after deductible",null,1,"$500.00 Copay after deductible",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,"$750.00 Copay after deductible",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,"$125.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,50,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,25,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,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,25,null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]

{"sheet":"Benefits Package 4","index":7,"n_rows":147,"n_cols":30,"rows_kept":147,"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],[141,0,141,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[139,0,139,1],[140,0,140,1],[142,0,142,1],[143,0,143,1],[144,0,144,1],[145,0,145,1],[146,0,146,1]]}
["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*",36046,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*"]
["36046MA0750147","Standard High Bronze HSA - Flex","36046MA075","MAN002","MAS001","MAF002","New","HMO","Expanded Bronze","Not Applicable","Yes","Both","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs",0.99670000000000003,null,null,"2024-01-01","2024-12-31","No",null,"No",null,"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","Yes"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,"Flex Providers will have a $250 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Provided in a Hospice-Outpatient setting.",null,"No","Yes"]
["Routine Dental Services (Adult)",null,null,"Not Covered"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Infertility treatment provided in an office or Hospital-Outpatient setting",null,"No","Yes"]
["Long-Term/Custodial Nursing Home Care",null,null,"Not Covered"]
["Private-Duty Nursing",null,null,"Not Covered"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per Year",null,"For Members age 19 and older.","Not EHB","No","Yes"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Cosmetic Surgery",null,null,"Not Covered"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,null,null,"No","Yes"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,"Routine Prenatal and Postnatal Care are covered in full.",null,"No","Yes"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,"Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered.",null,null,"No","Yes"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.",null,"No","Yes"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.","Substantially Equal","No","Yes"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years","Excluded for Members age 22 and older.","$2,000 per hearing aid every 36 months, per each hearing impaired ear.",null,"No","Yes"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered",null,null,null,null,null,"Substantially Equal","No","Yes"]
["Routine Foot Care",null,null,"Covered",null,null,null,"Excluded for all diagnosis, except for the treatment of Diabetes.",null,"Not EHB","No","Yes"]
["Acupuncture",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Weight Loss Programs",null,"Yes","Covered","Yes",3,"Months per Year","All Weight Loss Programs are excluded, except for Weight Watchers",null,null,"No","Yes"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year","Excluded for Members age 19 and older.",null,null,"No","Yes"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"Each Dependent under the age of 19 is eligible for coverage every 12 months for either prescription eyeglass frames and lenses or prescription contact lenses",null,"No","Yes"]
["Dental Check-Up for Children",null,"Yes","Covered","Yes",2,"Exam(s) per Year","Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Visits are limited to 60 per year combined.",null,"No","Yes"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,"Flex Providers will have a $25 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Basic Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Orthodontia – Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services","Not EHB","No","Yes"]
["Major Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services",null,"No","Yes"]
["Basic Dental Care – Adult",null,null,"Not Covered"]
["Orthodontia – Adult",null,null,"Not Covered"]
["Major Dental Care – Adult",null,null,"Not Covered"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,"Procedure performed in an office or Hospital-Outpatient setting","Not EHB","No","Yes"]
["Transplant",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Accidental Dental",null,null,"Covered",null,null,null,"Any treatment after 3 days is not covered.  All services are excluded, except for the following: Extraction of the teeth damaged in the injury when needed to avoid infection, Reimplantation and stabilization of dislodged teeth, Repositioning and stabilization of partly dislodged teeth, Suturing and suture removal, Medication received from the provider",null,"Not EHB","No","Yes"]
["Dialysis",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Radiation",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,"No Dental Care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment.","Provided in a Surgery-Outpatient setting.\nFlex Providers will have a $250 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"Provided in a Hospital- Acute Inpatient setting.","Not EHB","No","Yes"]
["Clinical Trials",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,"Excluded for Members age 18 and older","Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Early Intervention Services",null,null,"Covered",null,null,null,"Excluded for Members age 3 and older",null,"Not EHB","No","Yes"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Fitness Club Reimbursement",null,null,"Covered",null,null,null,"Excludes coverage for  fees or costs that you pay for country clubs, tennis clubs, social clubs (such as ski, riding or hiking clubs), gymnastics facilities, pool-only facilities, sports teams or leagues, spas, instructional dance studios and martial arts schools.","Coverage provided for the greater of 1 month membership or $300 at no charge.","Not EHB","No","Yes"]
["Childbirth Classes",null,null,"Covered",null,null,null,"In excess of 1 initial Childbirth Course or 1 refresher course per pregnancy will not be covered",null,"Not EHB","No","Yes"]
["Wigs",null,null,"Covered","Yes",1,"Item(s) per Year   ","All types of wigs are excluded, except for a synthetic monofilament wig",null,"Not EHB","No","Yes"]
["Inpatient Rehabilitation Services",null,null,"Covered","Yes",60,"Days per Year",null,null,"Not EHB","No","Yes"]
["Retail Health Clinics",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Low Protein Foods",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Inherited Metabolic Disorders - PKU",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Minor Dental Care - Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 20% coinsurance of covered dental services","Not EHB","No","Yes"]

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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,"Routine Foot Care",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,"Dental Check-Up 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,"Basic Dental Care – Child",null,null,null,null,null,"Orthodontia – Child",null,null,null,null,null,"Major Dental Care – Child",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Accidental Dental",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 ",null,null,null,null,null,"Fitness Club Reimbursement",null,null,null,null,null,"Childbirth Classes",null,null,null,null,null,"Wigs",null,null,null,null,null,"Inpatient Rehabilitation Services",null,null,null,null,null,"Retail Health Clinics",null,null,null,null,null,"Low Protein Foods",null,null,null,null,null,"Inherited Metabolic Disorders - PKU",null,null,null,null,null,"Minor Dental Care - Child"]
["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",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",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","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["36046MA0750147-00","Standard High Bronze HSA - Flex","Expanded Bronze","Standard Bronze Off Exchange Plan",0.65,null,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,3600,1900,0,0,3600,500,0,0,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8000,"$8000 per person | $16000 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,3600,"$3600 per person | $7200 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,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 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,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,60,null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$875.00 Copay after deductible",null,"$875.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$120.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$200.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$200.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$90.00 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,"No Charge","No Charge",null,"No Charge",60,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$135.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$90.00 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","No Charge after deductible",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,"$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,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$200.00 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","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$120.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750147-01","Standard High Bronze HSA - Flex","Expanded Bronze","Standard Bronze On Exchange Plan",0.65,null,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,3600,1900,0,0,3600,500,0,0,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8000,"$8000 per person | $16000 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,3600,"$3600 per person | $7200 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,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 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,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,60,null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$875.00 Copay after deductible",null,"$875.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$120.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$200.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$200.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$90.00 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,"No Charge","No Charge",null,"No Charge",60,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$135.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$90.00 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","No Charge after deductible",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,"$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,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$200.00 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","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$120.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]
["36046MA0750147-02","HMO","Expanded Bronze","Zero Cost Sharing Plan Variation",1,null,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,0,0,0,0,0,0,0,0,0,0,0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group","No",null,null,null,null,null,null,null,null,null,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
["36046MA0750147-03","Standard High Bronze HSA - Flex","Expanded Bronze","Limited Cost Sharing Plan Variation",0.65,null,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,3600,1900,0,0,3600,500,0,0,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8000,"$8000 per person | $16000 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,3600,"$3600 per person | $7200 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,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 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,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,60,null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$875.00 Copay after deductible",null,"$875.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$1500.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$120.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$200.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$200.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$90.00 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,"No Charge","No Charge",null,"No Charge",60,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$135.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$90.00 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","No Charge after deductible",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,"$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,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$200.00 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","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$90.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$55.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$120.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]

{"sheet":"Benefits Package 5","index":9,"n_rows":147,"n_cols":30,"rows_kept":147,"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],[141,0,141,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[139,0,139,1],[140,0,140,1],[142,0,142,1],[143,0,143,1],[144,0,144,1],[145,0,145,1],[146,0,146,1]]}
["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*",36046,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*"]
["36046MA0750150","HMO 3500 - Flex","36046MA075","MAN002","MAS001","MAF011","New","HMO","Expanded Bronze","Not Applicable","Yes","Both","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs",0.99670000000000003,null,null,"2024-01-01","2024-12-31","No",null,"No",null,"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","Yes"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,"Flex Providers will have a $250 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Provided in a Hospice-Outpatient setting.",null,"No","Yes"]
["Routine Dental Services (Adult)",null,null,"Not Covered"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Infertility treatment provided in an office or Hospital-Outpatient setting",null,"No","Yes"]
["Long-Term/Custodial Nursing Home Care",null,null,"Not Covered"]
["Private-Duty Nursing",null,null,"Not Covered"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per Year",null,"For Members age 19 and older.","Not EHB","No","Yes"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Cosmetic Surgery",null,null,"Not Covered"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,null,null,"No","Yes"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,"Routine Prenatal and Postnatal Care are covered in full.",null,"No","Yes"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,"subject to $125 per script max per prescription or prescription refill for 30 day Retail/$250 per script max per prescription or prescription refill for 90 day mail order",null,"No","Yes"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,"subject to $250 per script max per prescription or prescription refill for 30 day Retail/$750 per script max per prescription or prescription refill for 90 day mail order",null,"No","Yes"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,"Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered.","subject to $500 per script max per prescription or prescription refill for 30 day Retail/$1,500 per script max per prescription or prescription refill for 90 day mail order",null,"No","Yes"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.",null,"No","Yes"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.","Substantially Equal","No","Yes"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years","Excluded for Members age 22 and older.","$2,000 per hearing aid every 36 months, per each hearing impaired ear.",null,"No","Yes"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered",null,null,null,null,null,"Substantially Equal","No","Yes"]
["Routine Foot Care",null,null,"Covered",null,null,null,"Excluded for all diagnosis, except for the treatment of Diabetes.",null,"Not EHB","No","Yes"]
["Acupuncture",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Weight Loss Programs",null,"Yes","Covered","Yes",3,"Months per Year","All Weight Loss Programs are excluded, except for Weight Watchers",null,null,"No","Yes"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year","Excluded for Members age 19 and older.",null,null,"No","Yes"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"Each Dependent under the age of 19 is eligible for coverage every 12 months for either prescription eyeglass frames and lenses or prescription contact lenses",null,"No","Yes"]
["Dental Check-Up for Children",null,"Yes","Covered","Yes",2,"Exam(s) per Year","Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Visits are limited to 60 per year combined.",null,"No","Yes"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,"Flex Providers will have a $25 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Basic Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Orthodontia – Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services","Not EHB","No","Yes"]
["Major Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services",null,"No","Yes"]
["Basic Dental Care – Adult",null,null,"Not Covered"]
["Orthodontia – Adult",null,null,"Not Covered"]
["Major Dental Care – Adult",null,null,"Not Covered"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,"Procedure performed in an office or Hospital-Outpatient setting","Not EHB","No","Yes"]
["Transplant",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Accidental Dental",null,null,"Covered",null,null,null,"Any treatment after 3 days is not covered.  All services are excluded, except for the following: Extraction of the teeth damaged in the injury when needed to avoid infection, Reimplantation and stabilization of dislodged teeth, Repositioning and stabilization of partly dislodged teeth, Suturing and suture removal, Medication received from the provider",null,"Not EHB","No","Yes"]
["Dialysis",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Radiation",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,"No Dental Care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment.","Provided in a Surgery-Outpatient setting.\nFlex Providers will have a $250 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"Provided in a Hospital- Acute Inpatient setting.","Not EHB","No","Yes"]
["Clinical Trials",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,"subject to $250 per script max per prescription or prescription refill for 30 day Retail/$750 per script max per prescription or prescription refill for 90 day mail order","Not EHB","No","Yes"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,"Excluded for Members age 18 and older","Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Early Intervention Services",null,null,"Covered",null,null,null,"Excluded for Members age 3 and older",null,"Not EHB","No","Yes"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Fitness Club Reimbursement",null,null,"Covered",null,null,null,"Excludes coverage for  fees or costs that you pay for country clubs, tennis clubs, social clubs (such as ski, riding or hiking clubs), gymnastics facilities, pool-only facilities, sports teams or leagues, spas, instructional dance studios and martial arts schools.","Coverage provided for the greater of 1 month membership or $300 at no charge.","Not EHB","No","Yes"]
["Childbirth Classes",null,null,"Covered",null,null,null,"In excess of 1 initial Childbirth Course or 1 refresher course per pregnancy will not be covered",null,"Not EHB","No","Yes"]
["Wigs",null,null,"Covered","Yes",1,"Item(s) per Year   ","All types of wigs are excluded, except for a synthetic monofilament wig",null,"Not EHB","No","Yes"]
["Inpatient Rehabilitation Services",null,null,"Covered","Yes",60,"Days per Year",null,null,"Not EHB","No","Yes"]
["Retail Health Clinics",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Low Protein Foods",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Inherited Metabolic Disorders - PKU",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Minor Dental Care - Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 20% coinsurance of covered dental services","Not EHB","No","Yes"]

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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,"Routine Foot Care",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,"Dental Check-Up 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,"Basic Dental Care – Child",null,null,null,null,null,"Orthodontia – Child",null,null,null,null,null,"Major Dental Care – Child",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Accidental Dental",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 ",null,null,null,null,null,"Fitness Club Reimbursement",null,null,null,null,null,"Childbirth Classes",null,null,null,null,null,"Wigs",null,null,null,null,null,"Inpatient Rehabilitation Services",null,null,null,null,null,"Retail Health Clinics",null,null,null,null,null,"Low Protein Foods",null,null,null,null,null,"Inherited Metabolic Disorders - PKU",null,null,null,null,null,"Minor Dental Care - Child"]
["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",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",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","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["36046MA0750150-00","HMO 3500 - Flex","Expanded Bronze","Standard Bronze Off Exchange Plan",0.64339999999999997,null,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,3500,300,1700,0,2100,500,0,0,2800,10,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8500,"$8500 per person | $17000 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,3500,"$3500 per person | $7000 per group",0.2,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,500,null,null,null,null,null,null,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,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,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,40,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,"$1500.00 Copay after deductible",null,"$1500.00 Copay after deductible","Not Applicable",null,"Not Applicable","$250.00 Copay after deductible",null,"$250.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,5,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"50.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"50.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"50.00% Coinsurance after deductible","$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$65.00 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,"No Charge","No Charge",null,"No Charge",40,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",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","No Charge",null,1,"$25.00 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","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",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,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",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,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",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,1,30,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1]
["36046MA0750150-01","HMO 3500 - Flex","Expanded Bronze","Standard Bronze On Exchange Plan",0.64339999999999997,null,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,3500,300,1700,0,2100,500,0,0,2800,10,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8500,"$8500 per person | $17000 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,3500,"$3500 per person | $7000 per group",0.2,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,500,null,null,null,null,null,null,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,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,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,40,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,"$1500.00 Copay after deductible",null,"$1500.00 Copay after deductible","Not Applicable",null,"Not Applicable","$250.00 Copay after deductible",null,"$250.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,5,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"50.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"50.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"50.00% Coinsurance after deductible","$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$65.00 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,"No Charge","No Charge",null,"No Charge",40,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",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","No Charge",null,1,"$25.00 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","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",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,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",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,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",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,1,30,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1]
["36046MA0750150-02","HMO","Expanded Bronze","Zero Cost Sharing Plan Variation",1,null,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,0,0,0,0,0,0,0,0,0,0,0,0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group","No",null,null,null,null,null,null,null,null,null,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
["36046MA0750150-03","HMO 3500 - Flex","Expanded Bronze","Limited Cost Sharing Plan Variation",0.64339999999999997,null,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,3500,300,1700,0,2100,500,0,0,2800,10,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8500,"$8500 per person | $17000 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,3500,"$3500 per person | $7000 per group",0.2,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,500,null,null,null,null,null,null,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,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,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,40,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,"$1500.00 Copay after deductible",null,"$1500.00 Copay after deductible","Not Applicable",null,"Not Applicable","$250.00 Copay after deductible",null,"$250.00 Copay after deductible","Not Applicable",null,"Not Applicable","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,5,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"50.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"50.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,"50.00% Coinsurance after deductible","$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$65.00 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,"No Charge","No Charge",null,"No Charge",40,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",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","No Charge",null,1,"$25.00 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","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",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,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",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,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$1000.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","50.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$65.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",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,1,30,null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$40.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1]

{"sheet":"Benefits Package 6","index":11,"n_rows":147,"n_cols":30,"rows_kept":147,"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],[141,0,141,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[139,0,139,1],[140,0,140,1],[142,0,142,1],[143,0,143,1],[144,0,144,1],[145,0,145,1],[146,0,146,1]]}
["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*",36046,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*"]
["36046MA0750151","Basic Buy","36046MA075","MAN001","MAS001","MAF012","New","HMO","Catastrophic","Not Applicable","Yes","Both","No",null,0,"No","Allows Adult and Child-Only",null,"Yes","Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs",0.99670000000000003,null,null,"2024-01-01","2024-12-31","No",null,"No",null,"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,"Copay applies to the first 3 medical office visits per member. Deductible applies after the first 3 medical office visits per member.",null,"No","Yes"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Provided in a Hospice- Outpatient setting.",null,"No","Yes"]
["Routine Dental Services (Adult)",null,null,"Not Covered"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Infertility treatment provided in an office or Hospital-Outpatient setting",null,"No","Yes"]
["Long-Term/Custodial Nursing Home Care",null,null,"Not Covered"]
["Private-Duty Nursing",null,null,"Not Covered"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per Year",null,"For Members age 19 and older.","Not EHB","No","Yes"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital- Inpatient setting.",null,"No","Yes"]
["Cosmetic Surgery",null,null,"Not Covered"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,null,null,"No","Yes"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,"Routine Prenatal and Postnatal Care are covered in full.",null,"No","Yes"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,"No Charge for the first 3 Mental Health Outpatient office visits per member. Deductible applies after the first 3 Mental Health Outpatient office visits per member.",null,"No","Yes"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,"No Charge for the first 3 Mental Health Outpatient office visits per member. Deductible applies after the first 3 Mental Health Outpatient office visits per member.",null,"No","Yes"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,"Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered.",null,null,"No","Yes"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.",null,"No","Yes"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.","Substantially Equal","No","Yes"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years","Excluded for Members age 22 and older.","$2,000 per hearing aid every 36 months, per each hearing impaired ear.",null,"No","Yes"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered",null,null,null,null,null,"Substantially Equal","No","Yes"]
["Routine Foot Care",null,null,"Covered",null,null,null,"Excluded for all diagnosis, except for the treatment of Diabetes.",null,"Not EHB","No","Yes"]
["Acupuncture",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Weight Loss Programs",null,"Yes","Covered","Yes",3,"Months per Year","All Weight Loss Programs are excluded, except for Weight Watchers",null,null,"No","Yes"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year","Excluded for Members age 19 and older.",null,null,"No","Yes"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"Each Dependent under the age of 19 is eligible for coverage every 12 months for either prescription eyeglass frames and lenses or prescription contact lenses",null,"No","Yes"]
["Dental Check-Up for Children",null,"Yes","Covered","Yes",2,"Exam(s) per Year","Excluded for Members age 19 and older.",null,null,"No","Yes"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Visits are limited to 60 per year combined.",null,"No","Yes"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Basic Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.",null,null,"No","Yes"]
["Orthodontia – Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.",null,"Not EHB","No","Yes"]
["Major Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.",null,null,"No","Yes"]
["Basic Dental Care – Adult",null,null,"Not Covered"]
["Orthodontia – Adult",null,null,"Not Covered"]
["Major Dental Care – Adult",null,null,"Not Covered"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,"Procedure performed in an office or Hospital- Outpatient Setting","Not EHB","No","Yes"]
["Transplant",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital- Inpatient setting.",null,"No","Yes"]
["Accidental Dental",null,null,"Covered",null,null,null,"Any treatment after 3 days is not covered.  All services are excluded, except for the following: Extraction of the teeth damaged in the injury when needed to avoid infection, Reimplantation and stabilization of dislodged teeth, Repositioning and stabilization of partly dislodged teeth, Suturing and suture removal, Medication received from the provider","Copay applies to the first 3 medical office visits per member. Deductible applies after the first 3 medical office visits per member.","Not EHB","No","Yes"]
["Dialysis",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital- Outpatient setting",null,"No","Yes"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital- Outpatient setting",null,"No","Yes"]
["Radiation",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital- Outpatient setting",null,"No","Yes"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital- Outpatient setting",null,"No","Yes"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,"No Dental Care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment.","Provided in a Surgery- Outpatient setting.",null,"No","Yes"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,"Copay applies to the first 3 medical office visits per member. Deductible applies after the first 3 medical office visits per member.",null,"No","Yes"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital- Inpatient setting.",null,"No","Yes"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"Provided in a Hospital- Inpatient setting.","Not EHB","No","Yes"]
["Clinical Trials",null,null,"Covered",null,null,null,null,"Provided in a Hospital- Inpatient setting.","Not EHB","No","Yes"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,"Copay applies to the first 3 medical office visits per member. Deductible applies after the first 3 medical office visits per member.","Not EHB","No","Yes"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,"Excluded for Members age 18 and older","Provided in a Hospital- Inpatient setting.","Not EHB","No","Yes"]
["Early Intervention Services",null,null,"Covered",null,null,null,"Excluded for Members age 3 and older",null,"Not EHB","No","Yes"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,"Provided in a Hospital- Inpatient setting.","Not EHB","No","Yes"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.  Copay applies to the first 3 medical office visits per member. Deductible applies after the first 3 medical office visits per member.","Not EHB","No","Yes"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Fitness Club Reimbursement",null,null,"Covered",null,null,null,"Excludes coverage for  fees or costs that you pay for country clubs, tennis clubs, social clubs (such as ski, riding or hiking clubs), gymnastics facilities, pool-only facilities, sports teams or leagues, spas, instructional dance studios and martial arts schools.","Coverage provided for the greater of 1 month membership or $300 at no charge.","Not EHB","No","Yes"]
["Childbirth Classes",null,null,"Covered",null,null,null,"In excess of 1 initial Childbirth Course or 1 refresher course per pregnancy will not be covered",null,"Not EHB","No","Yes"]
["Wigs",null,null,"Covered","Yes",1,"Item(s) per Year   ","All types of wigs are excluded, except for a synthetic monofilament wig",null,"Not EHB","No","Yes"]
["Inpatient Rehabilitation Services",null,null,"Covered","Yes",60,"Days per Year",null,null,"Not EHB","No","Yes"]
["Retail Health Clinics",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Low Protein Foods",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Inherited Metabolic Disorders - PKU",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Minor Dental Care - Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.",null,"Not EHB","No","Yes"]

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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,"Routine Foot Care",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,"Dental Check-Up 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,"Basic Dental Care – Child",null,null,null,null,null,"Orthodontia – Child",null,null,null,null,null,"Major Dental Care – Child",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Accidental Dental",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 ",null,null,null,null,null,"Fitness Club Reimbursement",null,null,null,null,null,"Childbirth Classes",null,null,null,null,null,"Wigs",null,null,null,null,null,"Inpatient Rehabilitation Services",null,null,null,null,null,"Retail Health Clinics",null,null,null,null,null,"Low Protein Foods",null,null,null,null,null,"Inherited Metabolic Disorders - PKU",null,null,null,null,null,"Minor Dental Care - Child"]
["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",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",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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["36046MA0750151-00","Basic Buy","Catastrophic","Standard Catastrophic Off Exchange Plan",null,null,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,7900,0,0,0,5200,100,0,0,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7900,"$7900 per person | $15800 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,7900,"$7900 per person | $15800 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,3,null,null,null,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,null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1]
["36046MA0750151-01","Basic Buy","Catastrophic","Standard Catastrophic On Exchange Plan",null,null,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,7900,0,0,0,5200,100,0,0,2800,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7900,"$7900 per person | $15800 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,7900,"$7900 per person | $15800 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,3,null,null,null,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,null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1]

{"sheet":"Benefits Package 7","index":13,"n_rows":147,"n_cols":30,"rows_kept":147,"cut":false,"hidden":false,"merged":[[142,0,142,1],[143,0,143,1],[144,0,144,1],[145,0,145,1],[146,0,146,1],[141,0,141,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[135,0,135,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[139,0,139,1],[140,0,140,1],[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*",36046,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*"]
["36046MA0750176","Standard Low Silver HSA - Flex","36046MA075","MAN002","MAS001","MAF004","New","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, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs",0.99670000000000003,null,null,"2024-01-01","2024-12-31","No",null,"No",null,"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","Yes"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,"Flex Providers will have a $250 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,"Provided in a Hospice-Outpatient setting.",null,"No","Yes"]
["Routine Dental Services (Adult)",null,null,"Not Covered"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Infertility treatment provided in an office or Hospital-Outpatient setting",null,"No","Yes"]
["Long-Term/Custodial Nursing Home Care",null,null,"Not Covered"]
["Private-Duty Nursing",null,null,"Not Covered"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per Year",null,"For Members age 19 and older.","Not EHB","No","Yes"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Home Health Care Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Cosmetic Surgery",null,null,"Not Covered"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,null,null,"No","Yes"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,"Routine Prenatal and Postnatal Care are covered in full.",null,"No","Yes"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,"Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered.",null,null,"No","Yes"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.",null,"No","Yes"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,null,"Substantially Equal","No","Yes"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years","Excluded for Members age 22 and older.","$2,000 per hearing aid every 36 months, per each hearing impaired ear.",null,"No","Yes"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered",null,null,null,null,null,"Substantially Equal","No","Yes"]
["Routine Foot Care",null,null,"Covered",null,null,null,"Excluded for all diagnosis, except for the treatment of Diabetes.",null,"Not EHB","No","Yes"]
["Acupuncture",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Weight Loss Programs",null,"Yes","Covered","Yes",3,"Months per Year","All Weight Loss Programs are excluded, except for Weight Watchers",null,null,"No","Yes"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year","Excluded for Members age 19 and older.",null,null,"No","Yes"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"Each Dependent under the age of 19 is eligible for coverage every 12 months for either prescription eyeglass frames and lenses or prescription contact lenses",null,"No","Yes"]
["Dental Check-Up for Children",null,"Yes","Covered","Yes",2,"Exam(s) per Year","Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Visits are limited to 60 per year combined.",null,"No","Yes"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,"Flex Providers will have a $20 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Basic Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","Yes"]
["Orthodontia – Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services","Not EHB","No","Yes"]
["Major Dental Care – Child",null,"Yes","Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services",null,"No","Yes"]
["Basic Dental Care – Adult",null,null,"Not Covered"]
["Orthodontia – Adult",null,null,"Not Covered"]
["Major Dental Care – Adult",null,null,"Not Covered"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,"Procedure performed in an office or Hospital-Outpatient setting","Not EHB","No","Yes"]
["Transplant",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Accidental Dental",null,null,"Covered",null,null,null,"Any treatment after 3 days is not covered.  All services are excluded, except for the following: Extraction of the teeth damaged in the injury when needed to avoid infection, Reimplantation and stabilization of dislodged teeth, Repositioning and stabilization of partly dislodged teeth, Suturing and suture removal, Medication received from the provider",null,"Not EHB","No","Yes"]
["Dialysis",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Radiation",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","Yes"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,"No Dental Care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment.","Provided in a Surgery-Outpatient setting.\nFlex Providers will have a $250 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",null,"No","Yes"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","Yes"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"Provided in a Hospital- Acute Inpatient setting.","Not EHB","No","Yes"]
["Clinical Trials",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,"Excluded for Members age 18 and older","Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Early Intervention Services",null,null,"Covered",null,null,null,"Excluded for Members age 3 and older",null,"Not EHB","No","Yes"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","Yes"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","Yes"]
["Fitness Club Reimbursement",null,null,"Covered",null,null,null,"Excludes coverage for  fees or costs that you pay for country clubs, tennis clubs, social clubs (such as ski, riding or hiking clubs), gymnastics facilities, pool-only facilities, sports teams or leagues, spas, instructional dance studios and martial arts schools.","Coverage provided for the greater of 1 month membership or $300 at no charge.","Not EHB","No","Yes"]
["Childbirth Classes",null,null,"Covered",null,null,null,"In excess of 1 initial Childbirth Course or 1 refresher course per pregnancy will not be covered",null,"Not EHB","No","Yes"]
["Wigs",null,null,"Covered","Yes",1,"Item(s) per Year   ","All types of wigs are excluded, except for a synthetic monofilament wig",null,"Not EHB","No","Yes"]
["Inpatient Rehabilitation Services",null,null,"Covered","Yes",60,"Days per Year",null,null,"Not EHB","No","Yes"]
["Retail Health Clinics",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Low Protein Foods",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Inherited Metabolic Disorders - PKU",null,null,"Covered",null,null,null,null,null,"Not EHB","No","Yes"]
["Minor Dental Care - Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 20% coinsurance of covered dental services","Not EHB","No","Yes"]

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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,"Routine Foot Care",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,"Dental Check-Up 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,"Basic Dental Care – Child",null,null,null,null,null,"Orthodontia – Child",null,null,null,null,null,"Major Dental Care – Child",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Accidental Dental",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 ",null,null,null,null,null,"Fitness Club Reimbursement",null,null,null,null,null,"Childbirth Classes",null,null,null,null,null,"Wigs",null,null,null,null,null,"Inpatient Rehabilitation Services",null,null,null,null,null,"Retail Health Clinics",null,null,null,null,null,"Low Protein Foods",null,null,null,null,null,"Inherited Metabolic Disorders - PKU",null,null,null,null,null,"Minor Dental Care - Child"]
["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",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",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","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["36046MA0750176-00","Standard Low Silver HSA - Flex","Silver","Standard Silver Off Exchange Plan",0.71779999999999999,null,"Yes","Yes","Yes","A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.","No",1,null,2000,1200,0,0,2000,800,0,0,2000,500,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7050,"$7050 per person | $14100 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,"$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","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,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,30,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","No Charge after deductible",null,1,"$300.00 Copay after deductible",null,"$300.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,1,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$105.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$105.00 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,"$50.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$500.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge",null,"Not Applicable","No Charge",null,1,"$60.00 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,"No Charge","No Charge",null,"No Charge",30,null,"Not Applicable","Not Applicable",null,1,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",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","No Charge",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,"No Charge",null,"Not Applicable","No Charge",null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"Not Applicable",null,"Not Applicable",0.5,null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge after deductible",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,"$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,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$105.00 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","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",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","No Charge",null,1,"$30.00 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,"No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,1,"$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,1,"Not Applicable",null,"Not Applicable",0.2,null,1]

{"sheet":"Benefits Package 8","index":15,"n_rows":148,"n_cols":30,"rows_kept":148,"cut":false,"hidden":false,"merged":[[147,0,147,1],[136,0,136,1],[137,0,137,1],[138,0,138,1],[139,0,139,1],[140,0,140,1],[141,0,141,1],[142,0,142,1],[143,0,143,1],[144,0,144,1],[145,0,145,1],[146,0,146,1],[135,0,135,1],[124,0,124,1],[125,0,125,1],[126,0,126,1],[127,0,127,1],[128,0,128,1],[129,0,129,1],[130,0,130,1],[131,0,131,1],[132,0,132,1],[133,0,133,1],[134,0,134,1],[123,0,123,1],[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],[120,0,120,1],[121,0,121,1],[122,0,122,1],[111,0,111,1],[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],[108,0,108,1],[109,0,109,1],[110,0,110,1],[99,0,99,1],[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],[96,0,96,1],[97,0,97,1],[98,0,98,1],[87,0,87,1],[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],[84,0,84,1],[85,0,85,1],[86,0,86,1],[75,0,75,1],[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],[72,0,72,1],[73,0,73,1],[74,0,74,1],[5,25,5,29],[57,0,57,2],[57,3,57,9],[57,10,57,11],[63,0,63,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[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*",36046,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*"]
["36046MA0790073","PPO HSA 2000 - Flex","36046MA079","MAN003","MAS001","MAF004","New","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, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs",0.99670000000000003,null,null,"2024-01-01","2024-12-31","Yes","All Covered Benefits except for Emergency Care are covered at the Out of Network Cost Sharing.","Yes","All Covered Benefits except for Emergency Care are covered at the Out of Network Cost Sharing.","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,"Flex Providers will have a $250 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",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,"Provided in a Hospice-Outpatient setting.",null,"No","No"]
["Routine Dental Services (Adult)",null,null,"Not Covered"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Infertility treatment provided in an office or Hospital-Outpatient setting",null,"No","No"]
["Long-Term/Custodial Nursing Home Care",null,null,"Not Covered"]
["Private-Duty Nursing",null,null,"Not Covered"]
["Routine Eye Exam (Adult)",null,null,"Covered","Yes",1,"Exam(s) per Year",null,"For Members age 19 and older.","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","Yes"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","Yes"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,null,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,"Provided in a Hospital-Inpatient setting.",null,"No","No"]
["Cosmetic Surgery",null,null,"Not Covered"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",100,"Days per Year",null,null,null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,"Routine Prenatal and Postnatal Care are covered in full.",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,"Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered.",null,null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,"Same as outpatient PT/OT. Visits are limited to 60 per year combined.",null,"No","No"]
["Habilitation Services",null,"Yes","Covered","Yes",60,"Visit(s) per Year",null,null,"Substantially Equal","No","No"]
["Chiropractic Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",2000,"Dollars per 3 Years","Excluded for Members age 22 and older.","$2,000 per hearing aid every 36 months, per each hearing impaired ear.",null,"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",null,null,null,null,null,"Substantially Equal","No","No"]
["Routine Foot Care",null,null,"Covered",null,null,null,"Excluded for all diagnosis, except for the treatment of Diabetes.",null,"Not EHB","No","No"]
["Acupuncture",null,null,"Covered",null,null,null,null,null,"Not EHB","No","No"]
["Weight Loss Programs",null,"Yes","Covered","Yes",3,"Months per Year","All Weight Loss Programs are excluded, except for Weight Watchers",null,null,"No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered","Yes",1,"Exam(s) per Year","Excluded for Members age 19 and older.",null,null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered","Yes",1,"Item(s) per Year   ",null,"Each Dependent under the age of 19 is eligible for coverage every 12 months for either prescription eyeglass frames and lenses or prescription contact lenses",null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Covered","Yes",2,"Exam(s) per Year","Not covered for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","No"]
["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,"Visits are limited to 60 per year combined.",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,"Flex Providers will have a $20 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",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","Covered",null,null,null,"Not covered for Members age 19 and older.","Member is responsible for 0% coinsurance of covered dental services",null,"No","No"]
["Orthodontia – Child",null,null,"Covered",null,null,null,"Not covered for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services","Not EHB","No","No"]
["Major Dental Care – Child",null,"Yes","Covered",null,null,null,"Not covered for Members age 19 and older.","Member is responsible for 50% coinsurance of covered dental services",null,"No","No"]
["Basic Dental Care – Adult",null,null,"Not Covered"]
["Orthodontia – Adult",null,null,"Not Covered"]
["Major Dental Care – Adult",null,null,"Not Covered"]
["Abortion for Which Public Funding is Prohibited",null,null,"Covered",null,null,null,null,"Procedure performed in an office or Hospital-Outpatient setting","Not EHB","No","No"]
["Transplant",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.",null,"No","No"]
["Accidental Dental",null,null,"Covered",null,null,null,"Any treatment after 3 days is not covered. All services are excluded, except for the following: Extraction of the teeth damaged in the injury when needed to avoid infection, Reimplantation and stabilization of dislodged teeth, Repositioning and stabilization of partly dislodged teeth, Suturing and suture removal, Medication received from the provider.",null,"Not EHB","No","No"]
["Dialysis",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,"Provided in a Hospital-Outpatient setting.",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,"Provided in a Hospital-Outpatient setting.",null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,"No dental care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment.","Provided in a Surgery-Outpatient setting.\nFlex Providers will have a $250 Copayment per visit after the Deductible has been met. The applicable cost-sharing will apply for Other Plan Providers.",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,"Provided in a Hospital-Inpatient setting.",null,"No","No"]
["Gender Affirming Care",null,null,"Covered",null,null,null,null,"Provided in a Hospital- Acute Inpatient setting.","Not EHB","No","No"]
["Clinical Trials",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","No"]
["Diabetes Care Management",null,null,"Covered",null,null,null,null,null,"Not EHB","No","No"]
["Off Label Prescription Drugs",null,null,"Covered",null,null,null,null,null,"Not EHB","No","No"]
["Congenital Anomaly, including Cleft Lip/Palate",null,null,"Covered",null,null,null,"Excluded for Members age 18 and older","Provided in a Hospital-Inpatient setting.","Not EHB","No","No"]
["Early Intervention Services",null,null,"Covered",null,null,null,"Not covered for Members age 3 and older.",null,"Not EHB","No","No"]
["Nutrition/Formulas",null,null,"Covered",null,null,null,null,null,"Not EHB","No","No"]
["Bone Marrow Transplants for Treatment of Breast Cancer",null,null,"Covered",null,null,null,null,"Provided in a Hospital-Inpatient setting.","Not EHB","No","No"]
["Cardiac Rehabilitation",null,null,"Covered",null,null,null,null,null,"Not EHB","No","No"]
["Contraceptive Services",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","No"]
["Hormone Replacement Therapy (HRT)",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","No"]
["Human Leukocyte Antigen Testing",null,null,"Covered",null,null,null,null,null,"Not EHB","No","No"]
["Hypodermic Syringes or Needles ",null,null,"Covered",null,null,null,null,"Covered under the pharmacy benefit.","Not EHB","No","No"]
["Fitness Club Reimbursement",null,null,"Covered",null,null,null,"Excludes coverage for fees or costs that you pay for country clubs, tennis clubs, social clubs (such as ski, riding or hiking clubs), gymnastics facilities, pool-only facilities, sports teams or leagues, spas, instructional dance studios and martial arts schools.","Coverage provided for the greater of 1 month membership or $300 at no charge.","Not EHB","No","No"]
["Childbirth Classes",null,null,"Covered",null,null,null,"In excess of 1 initial Childbirth Course or 1 refresher course per pregnancy will not be covered",null,"Not EHB","No","No"]
["Wigs",null,null,"Covered","Yes",1,"Item(s) per Year   ","All types of wigs are excluded, except for a synthetic monofilament wig",null,"Not EHB","No","No"]
["Inpatient Rehabilitation Services",null,null,"Covered","Yes",60,"Days per Year",null,null,"Not EHB","No","No"]
["Retail Health Clinics",null,null,"Covered",null,null,null,null,null,"Not EHB","No","No"]
["Low Protein Foods",null,null,"Covered",null,null,null,null,null,"Not EHB","No","No"]
["Inherited Metabolic Disorders - PKU",null,null,"Covered",null,null,null,null,null,"Not EHB","No","No"]
["Non-Emergency Care When Traveling Outside the U.S.",null,null,"Covered",null,null,null,null,"Covered benefits will be applied to the Out of Network Deductible and Out of Pocket Max.","Not EHB","Yes","No"]
["Minor Dental Care - Child",null,null,"Covered",null,null,null,"Excluded for Members age 19 and older.","Member is responsible for 20% coinsurance of covered dental services","Not EHB","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,"Routine Foot Care",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,"Dental Check-Up 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,"Basic Dental Care – Child",null,null,null,null,null,"Orthodontia – Child",null,null,null,null,null,"Major Dental Care – Child",null,null,null,null,null,"Abortion for Which Public Funding is Prohibited",null,null,null,null,null,"Transplant",null,null,null,null,null,"Accidental Dental",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 ",null,null,null,null,null,"Fitness Club Reimbursement",null,null,null,null,null,"Childbirth Classes",null,null,null,null,null,"Wigs",null,null,null,null,null,"Inpatient Rehabilitation Services",null,null,null,null,null,"Retail Health Clinics",null,null,null,null,null,"Low Protein Foods",null,null,null,null,null,"Inherited Metabolic Disorders - PKU",null,null,null,null,null,"Non-Emergency Care When Traveling Outside the U.S.",null,null,null,null,null,"Minor Dental Care - Child"]
["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",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",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","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["36046MA0790073-00","PPO HSA 2000 - Flex","Silver","Standard Silver Off Exchange Plan",0.7177,null,"Yes","Yes","No",null,"No",1,null,2000,1200,0,0,2000,800,0,0,2000,400,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7050,"$7050 per person | $14100 per group",null,null,14100,"$14100 per person | $28200 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,"$2000 per person | $4000 per group",0,null,null,null,4000,"$4000 per person | $8000 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","$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$60.00 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","No Charge after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible",30,null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","$300.00 Copay after deductible",null,"$300.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge after deductible",null,"No Charge after deductible","No Charge after deductible",null,"No Charge after deductible","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","No Charge",null,"20.00% Coinsurance after deductible","$750.00 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","$750.00 Copay per Stay 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","$750.00 Copay per Stay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$30.00 Copay after deductible",null,"$30.00 Copay after deductible","Not Applicable",null,"Not Applicable","$60.00 Copay after deductible",null,"$60.00 Copay after deductible","Not Applicable",null,"Not Applicable","$105.00 Copay after deductible",null,"$105.00 Copay after deductible","Not Applicable",null,"Not Applicable","$105.00 Copay after deductible",null,"$105.00 Copay after deductible","Not Applicable",null,"Not Applicable","$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$60.00 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,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",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","No Charge",null,"20.00% Coinsurance after deductible","$60.00 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","No Charge",null,"No Charge","No Charge",null,"No Charge",30,null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge",null,"Not Applicable","No Charge",null,0.2,"$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$60.00 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","$60.00 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","No Charge",null,0.2,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"Not Applicable",null,"Not Applicable",0.5,null,0.5,"No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","$750.00 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","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","$60.00 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,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","$500.00 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","$750.00 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","$750.00 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","$105.00 Copay after deductible",null,"$105.00 Copay after deductible","Not Applicable",null,"Not Applicable","$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","$750.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","No Charge",null,"Not Applicable","No Charge",null,"20.00% Coinsurance after deductible","$30.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$60.00 Copay after deductible",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible","$60.00 Copay after deductible",null,"$60.00 Copay after deductible","Not Applicable",null,"Not Applicable","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","No Charge",null,"No Charge","Not Applicable",null,"Not Applicable","20.00% Coinsurance after deductible",null,"20.00% Coinsurance after deductible","$750.00 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","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","No Charge after deductible",null,"Not Applicable","No Charge after deductible",null,"20.00% Coinsurance after deductible","Not Applicable",null,"Not Applicable",0.2,null,0.2,"Not Applicable",null,"Not Applicable","Not Applicable",null,"20.00% Coinsurance after deductible"]

{"sheet":"DefaultBP","index":17,"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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["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"]

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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"]
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{"sheet":"Names","index":19,"n_rows":141,"n_cols":9,"rows_kept":141,"cut":false,"hidden":true,"merged":[]}
["Individual","AK","Yes","Accidental Ingestion of a Controlled Drug",null,"CSV Code Name","Already Ran AVC","Data Modified After Running AVC","Modified Fields"]
["SHOP (Small Group)","AL",null,"Anesthetics",null,"Sheet3",true,false]
[null,"AR",null,"Applied Behavior Analysis Based Therapies",null,"Sheet6",false,false]
["Bronze","AZ",null,"Attention Deficit Disorder",null,"Sheet13",false,false]
["Expanded Bronze","CA",null,"Autism Spectrum Disorders",null,"Sheet14",false,false]
["Silver","CO",null,"Blood and Blood Services",null,"Sheet15",false,false]
["Gold","CT",null,"Bone Marrow Testing",null,"Sheet16",false,false]
["Platinum","DC",null,"Bone Marrow Transplant",null,"Sheet19",false,false]
["Catastrophic","DE",null,"Bone Marrow Transplants for Treatment of Breast Cancer",null,"Sheet20",false,false]
[null,"FL",null,"Bones/Joints"]
["Yes","GA",null,"Brain Injury"]
["No","HI",null,"Breast Implant Removal"]
[null,"IA",null,"Breast Reconstructive Surgery"]
["Indemnity","ID",null,"Cancer Treatments"]
["PPO","IL",null,"Cardiac Rehabilitation"]
["HMO","IN",null,"Clinical Trials"]
["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"]