Silver Standard, Silver, ST, INN, Excellus BCBS EPO, Dep25, Pediatric Dental

Health Insurance Plan Details (2024 Plan)

by Excellus Health Plan, Inc.

Monthly Premium

EPO
$ubsidy
Silver
Deductible
$2,100 /yr
Max Out-of-Pocket
$9,450 /yr

Details

Deductible (per individual) $2,100 /yr
Deductible (per family) $4,200 /yr
Max Out-of-Pocket (per individual) $9,450 /yr
Max Out-of-Pocket (per family) $18,900 /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? Yes
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $30 Copay after deductible
Specialist Visit $65 Copay after deductible
Emergency Room $500 Copay after deductible
Inpatient Facility $1500 Copay per Stay after deductible
Inpatient Physician $150 Copay after deductible
Drug Costs
Generic Drugs $15 Copay
Preferred Brand Drugs $40 Copay
Non-preferred Brand Drugs $75 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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