SimplyBlue Plus Silver 16 by Excellus
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Plan Information
- Plan Name
- SimplyBlue Plus Silver 16
- Insurance Company
- Excellus
In Network Benefits
- Office Co-pay
- 20% after deductible
- Specialist Co-pay
- 20% after deductible
- Hospital Co-pay
- 20% after deductible
- Emergency Room
- 20% after deductible
- Referrals Needed
- No
- Rx: Generic/Brand/High Brand
- $5/$45/$90 after deductible
- In-Network Deductible (single/family)
- $3,200/$6,400
- In-Network Co-Insurance
- 20%
- Max Out of Pocket (single/family)
- $6,550/$12,100
Out Of Network Benefits
- Co-Insurance
- 40%
- Deductible
- $3,200/$6,400
- Out of Pocket Max (single/family)
- $6,550/$12,100
Other Benefits
- Vision/Dental
- Pediatric Vision and Dental; Adult Vision Only
- Renewal Date
- Annual
- HSA Eligible
- Yes
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