Platinum Select NS by Excellus
Scroll down to the Summary of Benefits PDF
Plan Information
- Plan Name
- Platinum Select NS
- Insurance Company
- Excellus
In Network Benefits
- Office Co-pay
- $15
- Specialist Co-pay
- $25
- Hospital Co-pay
- $750
- Emergency Room
- $150
- Referrals Needed
- No
- Rx: Generic/Brand/High Brand
- $10/$35/$70
- In-Network Deductible (single/family)
- $0
- In-Network Co-Insurance
- 0%
- Max Out of Pocket (single/family)
- $6,350/ $12,700
Out Of Network Benefits
- Co-Insurance
- N/A
- Out of Pocket Max (single/family)
- N/A
Other Benefits
- Vision/Dental
- Pediatric Vision
- Renewal Date
- 01/01/2018
- HSA Eligible
- No
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