SimplyBlue Plus Platinum 3 by Excellus
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Plan Information
- Plan Name
- SimplyBlue Plus Platinum 3
- Insurance Company
- Excellus
In Network Benefits
- Office Co-pay
- $25
- Specialist Co-pay
- $40
- Hospital Co-pay
- $500
- Emergency Room
- $150
- Referrals Needed
- No
- Rx: Generic/Brand/High Brand
- $5/$30/$50
- In-Network Deductible (single/family)
- $0
- In-Network Co-Insurance
- 0%
- Max Out of Pocket (single/family)
- $4,500/$9,000
Out Of Network Benefits
- Deductible (single/family)
- $500/$1,000
- Co-Insurance
- 20%
- Out of Pocket Max (single/family)
- $4,500/$9,000
Other Benefits
- Vision/Dental
- Pediatric Vision and Dental; Adult Vision Only
- Renewal Date
- Annual
- HSA Eligible
- No
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