Bronze Select, Expanded Bronze, NS, INN, Excellus BCBS EPO, Dep25, Adult Dental, Adult Vision, Preventive Rx, Acupuncture

Health Insurance Plan Details (2025 Plan)

SBC doc

doctor lookup

EPO

HSA

Bronze

Deductible (per individual)	$5,500 /yr
Deductible (per family)	$11,000 /yr
Max Out-of-Pocket (per individual)	$7,500 /yr
Max Out-of-Pocket (per family)	$15,000 /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

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	40.00% Coinsurance after deductible
Non-preferred Brand Drugs	50.00% Coinsurance after deductible
Specialty Drugs	Not Applicable

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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