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Gold Select, Gold, NS, INN, Univera EPO Local, Dep29, Adult Dental, Adult Vision, Acupuncture
Health Insurance Plan Details (2025 Plan)
by Excellus Health Plan, Inc.
Monthly Premium
EPO
$ubsidy
Gold
- Deductible
- $1,050 /yr
- Max Out-of-Pocket
- $8,750 /yr
Details
| Deductible (per individual) | $1,050 /yr |
| Deductible (per family) | $2,100 /yr |
| Max Out-of-Pocket (per individual) | $8,750 /yr |
| Max Out-of-Pocket (per family) | $17,500 /yr |
| Drug Deductible (per individual) | |
| Drug Deductible (per family) | |
| Drug Max Out-of-Pocket (per individual) | |
| Drug Max Out-of-Pocket (per family) | |
| Plan Type | EPO |
| Includes Child Dental? | No |
| Includes Adult Dental? | Yes |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | $25 Copay after deductible |
| Specialist Visit | $40 Copay after deductible |
| Emergency Room | $500 Copay after deductible |
| Inpatient Facility | $1000 Copay per Stay after deductible |
| Inpatient Physician | No Charge after deductible |
| Generic Drugs | $10 Copay |
| Preferred Brand Drugs | $35 Copay |
| Non-preferred Brand Drugs | $70 Copay |
| Specialty Drugs | Not Applicable |
Plan Documents
| Summary of Benefits and Coverage | SBC doc |
| Provider Directory | Doctor lookup |
| Drug Formulary List | n/a |
* Figures shown are only for in-network medical costs
** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible
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