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SBC and Glossary

EXCELLUS SUMMARY OF BENEFITS AND COVERAGE (SBC) 
The SBCs below were prepared by Excellus utilizing the template format as required by the Healthcare Law.  Please keep in mind, the document states that it is only a summary.  The document also indicates that the required examples should not be utilized in estimating your actual costs under your plan.  

Blue PPO - A

  • 2020 Blue PPO with $15/$30/$60 Prescription Copays Click here
  • 2020 Blue PPO with $20/$35/$65 Prescription Copays Click here


Blue PPO 2 - B

  • 2020 Blue PPO 2 with $10/$25/$55 Prescription Copays  Click here

Blue PPO 3 - J

  • 2020 Blue PPO 3 with $10/$25/$55 Prescription Copays  Click here


Classic Blue (Indemnity) - C

  • 2020 Classic Blue (Indemnity) with $15/$30/$60 Prescription Copays Click here
  • 2020 Classic Blue (Indemnity) with $20/$35/$65 Prescription Copays effective 5/1/20                               (same as above except Rx copays)


Glossary of Health Coverage and Medical Terms – Click here.

Health Insurance Policies Acknowledgment Form – Click here.