Bronze Standard HSA, Expanded Bronze, ST, INN, Excellus BCBS EPO, Dep29

Health Insurance Plan Details (2024 Plan)

by Excellus Health Plan, Inc.

Monthly Premium

EPO
$ubsidy
HSA
Bronze
Deductible
$6,100 /yr
Max Out-of-Pocket
$7,150 /yr

Details

Deductible (per individual) $6,100 /yr
Deductible (per family) $12,200 /yr
Max Out-of-Pocket (per individual) $7,150 /yr
Max Out-of-Pocket (per family) $14,300 /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? No
Medical Services
Preventive Care No Charge
Primary Care Visit 50.00% Coinsurance after deductible
Specialist Visit 50.00% Coinsurance after deductible
Emergency Room 50.00% Coinsurance after deductible
Inpatient Facility 50.00% Coinsurance after deductible
Inpatient Physician 50.00% Coinsurance after deductible
Drug Costs
Generic Drugs $10 Copay after deductible
Preferred Brand Drugs $35 Copay after deductible
Non-preferred Brand Drugs $70 Copay after deductible
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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