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plans,
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directly.

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Excellus - Healthy
Blue HB-CD-60 |
| PPO policy with in- and
out-of-network coverage, no referrals needed. There is a
$2,000 (single) $6,000 (family) in-network and out of
network deductible with an 80% coinsurance. Coinsurance
for out of network is 60% The primary in-network copay
is $40 and specialist copay is $60 per visit. With
inpatient hospital on both in- and out-of-network you
must meet the deductible and coinsurance. Emergency room
visits are a $350 copay. Preventive Services are covered
in full. The prescription coverage is $5/40%/50% after a
$500/$1000 family deductible Full time dependant
coverage to age 26. |
| |
Quarterly |
|
Small
Group |
Sole Proprietor |
| Employee
|
$1,208.88 |
$1,328.28 |
| Employee
+ Spouse |
$2,402.85 |
$2,641.62 |
| Employee
+ Child(ren) |
$2,429.37 |
$2,671.62 |
| Family |
$3,345.51 |
$3,678.54 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
Excellus - Simply
Blue SB-CD-14 |
| PPO policy with in- and
out-of-network coverage, no referrals needed. There is a
$500 (single) $1,500 (family) in-network and out of
network deductible with an 80% coinsurance. Coinsurance
for out of network is 60% The primary in-network copay
is $25 and specialist copay is $40 per visit. In-patient
hospital stays are subject to the deductible and
coinsurance. Emergency room visits are a $250 copay.
Preventive Services are covered in full. The
prescription coverage is $7.00 generic only. Full time
dependant coverage to age 26. |
| |
Quarterly |
|
Small
Group |
Sole Proprietor |
| Employee
|
$1,340.04 |
$1,472.44 |
| Employee
+ Spouse |
$2,665.17 |
$2,930.19 |
| Employee
+ Child(ren) |
$2,709.27 |
$2,978.67 |
| Family |
$3,730.17 |
$4,103.37 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
Excellus - Simply
Blue SB-C-23 |
| This policy is an PPO with
both in- and out-of-network coverage, no referrals
needed. There are no in-network deductibles or
coinsurance. Out of network is $500/$1500 family and
80/20% coinsurance. The primary in-network copay is $30
and specialist copay is $50 per visit. In-patient
hospital hospital stays are subject to a $500 copayment
in-network and deductibles and coinsurance out of
network. Emergency room visits are a $250 copay. The
prescription coverage is $7 Generic Only.Dependant
coverage to 26. Preventive Services Covered in full. |
| |
Quarterly |
|
Small
Group |
Sole Proprietor |
| Employee
|
$1,421.61 |
$1,562.28 |
| Employee
+ Spouse |
$2,828.31 |
$3,109.65 |
| Employee
+ Child(ren) |
$2,875.44 |
$3,161.49 |
| Family |
$3,960.93 |
$4,355.20 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
Excellus - Healthy Blue
HB-CD-10E |
| PPO policy with in- and
out-of-network coverage, no referrals needed. There is a
$1,000 (single) $3,000 (family) in-network and out of
network deductible with an 80% coinsurance. Coinsurance
for out of network is 60% The primary in-network copay
is $30 and specialist copay is $50 per visit. With
inpatient hospital on both in- and out-of-network you
must meet the deductible and coinsurance. Emergency room
visits are a $250 copay. Preventive Services are covered
in full. The prescription coverage is $5/$35/$70 Full
time dependant coverage to age 26. |
| |
Quarterly |
|
Small
Group |
Sole Proprietor |
| Employee
|
$1,468.80 |
$1,614.21 |
| Employee
+ Spouse |
$2,922.66 |
$3,213.42 |
| Employee
+ Child(ren) |
$2,949.96 |
$3,243.48 |
| Family |
$4,063.74 |
$4,468.59 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
Excellus - Healthy
Blue HB-C-48-E |
| This policy is an PPO with
both in- and out-of-network coverage, no referrals
needed. In and out of network deductibles of $500 Single
and $1,500 Family with 80% coinsurance apply. In-network
Copays are $30 Primary, $50 Specialist, $250 Same Day
Surgery and ER. All out of network services are subject
to deductible and coinsurance. Preventive services are
covered in full. $5/$35/$70 Drug. Dependants to 26. |
| |
Quarterly |
|
Small
Group |
Sole Proprietor |
| Employee
|
$1,556.19 |
$1,710.36 |
| Employee
+ Spouse |
$3,097.47 |
$3,405.69 |
| Employee
+ Child(ren) |
$3,127.98 |
$3,439.26 |
| Family |
$4,309.38 |
$4,738.80 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
Excellus - Healthy
Blue HB-CD-38E |
| This policy is a PPO.
Deductibles are $500 Individual/$1500 family for in and
out of network. Copays are $25 Doctor and $40
Specialist. 80/20% coinsurance in network, 60/40% out of
network. $250 Copay for emergency room visits
Prescription drugs are $5/$35/$70 with no deductibles.
Dependants to age 26 and preventive care is covered in
full. |
| |
Quarterly |
|
Small
Group |
Sole Proprietor |
| Employee
|
$1,587.57 |
$1,744.86 |
| Employee
+ Spouse |
$3,160.23 |
$3,474.75 |
| Employee
+ Child(ren) |
$3,191.97 |
$3,509.67 |
| Family |
$4,397.58 |
$4,835.85 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
Excellus - Healthy
Blue HB-C-42-E |
| This policy is an PPO with
both in- and out-of-network coverage, no referrals
needed. There is NO in-network Deductible or
coinsurance. Out of Network deductibles of $500 Single
and $1,500 Family with 80% coinsurance apply. In-network
Copays are $30 Primary, $50 Specialist, $500 Hospital,
$250 Same Day Surgery and ER. Preventive services are
covered in full. Out of network services are subject to
deductibles and coinsurance. $5/$35/$70 Drug. Dependants
to 26 |
| |
Quarterly |
|
Small Group |
Sole Proprietor |
| Employee
|
$1,669.14 |
$1,834.59 |
| Employee
+ Spouse |
$3,232.37 |
$3,654.21 |
| Employee
+ Child(ren) |
$3,358.14 |
$3,692.49 |
| Family |
$4,626.84 |
$5,088.00 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
HMO
Blue 30/50 |
| This policy is an HMO with
no out-of-network coverage and referrals are required.
This plan is has a $30 primary and $50 specialist office
visit copay. Inpatient hospital has a $750 copay and an
emergency room visit has a $150 copay. The prescription
coverage is $10/$30/$50 with no deductible. Full time
dependant coverage to age 26. |
| |
Quarterly |
|
Small
Group |
Sole Proprietor |
| Employee
|
$1,790.73 |
$1,968.39 |
| Employee
+ Spouse |
$3,566.24 |
$3,921.48 |
| Employee
+ Child(ren) |
$3,602.55 |
$3,961.32 |
| Family |
$4,963.92 |
$5,458.80 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
HMO Blue 25 |
| This policy is an HMO with
no out-of-network coverage and referrals are required.
This plan is has a $25 primary and $40 specialist office
visit copay. Inpatient hospital has a $500 copay and an
emergency room visit has a $150 copay. The prescription
coverage is $10/$30/$50 with no deductible. Full time
dependant coverage to age 26. |
| |
Quarterly |
|
Small Group |
Sole Proprietor |
| Employee
|
$1,851.45 |
$2,035.14 |
| Employee
+ Spouse |
N/A |
N/A |
| Employee
+ Child(ren) |
N/A |
N/A |
| Family |
$4,752.18 |
$5,225.88 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
Simply Blue -
5500/11000 |
|
This policy is an PPO with both in- and
out-of-network coverage, no referrals needed. You must
meet an individual deductible of $5,500 or a family
deductible of $11,000. From then on, the policy pays
100% of covered benefits. All preventive care is covered
in full (no deductible applies). Prescription drugs are
covered at 100% after you meet the policy deductible. |
| |
Quarterly |
|
Small Group |
Sole Proprietor |
| Employee
|
$676.44 |
$742.59 |
| Employee
+ Spouse |
$1,337.94 |
$1,470.24 |
| Employee
+ Child(ren) |
$1,363.74 |
$1,498.62 |
| Family |
$1,875.57 |
$2,061.63 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
Simply Blue -
2600/5200 |
|
This policy is an PPO with both in- and
out-of-network coverage, no referrals needed. You must
meet an individual deductible of $2,600 or a family
deductible of $5,200. From then on, the policy pays 100%
of covered benefits. All preventive care is covered in
full (no deductible applies). Prescription drugs are
covered at $5/$35/$70 after the deductible has been
satisfied |
| |
Quarterly |
|
Small Group |
Sole Proprietor |
| Employee
|
$963.96 |
$1,058.85 |
| Employee
+ Spouse |
$1,912.98 |
$2,102.79 |
| Employee
+ Child(ren) |
$1,950.27 |
$2,143.80 |
| Family |
$2,684.67 |
$2,951.64 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
Simply Blue - 1300/2600 |
|
This policy is an PPO with both in- and
out-of-network coverage, no referrals needed. You must
meet an individual deductible of $1,300 or a family
deductible of $2,600. coinsurance applies to a maximum
out of pocket expense of $3,000 single/$6,000 family. RX
is $5/35/70 after deductible |
| |
Quarterly |
|
Small Group |
Sole Proprietor |
| Employee
|
$1,115.70 |
$1,225.77 |
| Employee
+ Spouse |
$2,216.43 |
$2,436.66 |
| Employee
+ Child(ren) |
$2,257.35 |
$2,481.60 |
| |
Plan Selection |
Plan Selection |
| |
Instructions |
Instructions |
| |
Application |
Application |
|
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