SimplyBlue Plus Silver 18 by Excellus
Scroll down to the Summary of Benefits PDF
Plan Information
- Plan Name
- SimplyBlue Plus Silver 18
- Insurance Company
- Excellus
In Network Benefits
- Office Co-pay
- $50
- Specialist Co-pay
- $75
- Hospital Co-pay
- 30% after deductible
- Emergency Room
- $500
- Referrals Needed
- No
- Rx: Generic/Brand/High Brand
- $10/$45/$90
- In-Network Deductible (single/family)
- $6,550/$13,100
- In-Network Co-Insurance
- 30%
- Max Out of Pocket (single/family)
- $7,500/$15,000
Out Of Network Benefits
- Co-Insurance
- 50%
- Deductible
- $6,550/$13,100
- Out of Pocket Max (single/family)
- $7,500/$15,000
Other Benefits
- Vision/Dental
- Pediatric Vision and Dental; Adult Vision Only
- Renewal Date
- Annual
- HSA Eligible
- No
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