Essential Plan 200-250 by Excellus BCBS
Scroll down to the Summary of Benefits PDF
Plan Information
- Plan Name
- Essential Plan 200-250
- Insurance Company
- Excellus BCBS
In Network Benefits
- Office Co-pay
- $15 copayment
- Specialist Co-pay
- $25 copayment
- Hospital Co-pay
- $150 copayment
- Emergency Room
- $75 copayment
- Referrals Needed
- No
- Rx: Generic/Brand/High Brand
- $6/$15/$30 copayment
- In-Network Deductible (single/family)
- $0
- In-Network Co-Insurance
- Not Applicable
- Max Out-of-Pocket (single/family)
- $2,000
Out Of Network Benefits
- Deductible (single/family)
- Not Applicable
- Co-Insurance
- Not Applicable
- Out-of-Pocket Max (single/family)
- Not Applicable
Other Benefits
- Vision/Dental
- Covered
- Renewal Date
- 12/31/2024
- HSA Eligible
- No
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