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		Bronze Secure Plus 3 NS INN Excellus BCBS EPO Adult/Family Dental Dep25 Acupuncture

You Pay

$0.00

Price Per Month	$394.86	Metal	Bronze	Overall Quality Rating	Quality Details
Maximum Out of Pocket	$8700 / $8700 per person \| $17400 per group	Out-of-Network Coverage	No	Allows Health Savings Account	No
Plan Id	78124NY0900023	Persons Covered	individual	Deductible	$8700 / $8700 per person \| $17400 per group
Specialist(s) Referral Required No

Design	Free preventive care and flu shots. Telemedicine services covered at no cost after your deductible is met. Your first 3 visits to your Primary Care Physician are covered in full and are not subject to the deductible. No referrals needed, and no need to identify a Primary Care Physician. Coverage for services in network only with access to 100% of local hospitals and 99% of doctors throughout 31 counties in New York State. If you are traveling, BlueCard provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to healthy perks including a 24/7 Nurse Call Line and Blue365 discounts on fitness gear, weight loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.

Design

Free preventive care and flu shots. Telemedicine services covered at no cost after your deductible is met. Your first 3 visits to your Primary Care Physician are covered in full and are not subject to the deductible. No referrals needed, and no need to identify a Primary Care Physician. Coverage for services in network only with access to 100% of local hospitals and 99% of doctors throughout 31 counties in New York State. If you are traveling, BlueCard provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to healthy perks including a 24/7 Nurse Call Line and Blue365 discounts on fitness gear, weight loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.

Click on the benefit categories below to learn more about this plan's covered benefits and services. To see a full list of the benefits and services, visit the "Summary of Benefits" link under "Plan Documents" at the bottom of this page.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Routine Eye Exam (Adult)	0% Coinsurance after deductible	100%

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Routine Eye Exam for Children	0% Coinsurance after deductible	100%	Emergency, preventive and routine vision care for children.
Contact Lenses for Children	0% Coinsurance after deductible	100%	One prescribed lenses and frames in a 12-month period.
Eye Glasses for Children	0% Coinsurance after deductible	100%	One prescribed lenses and frames in a 12-month period.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Second Opinion	0% Coinsurance after deductible	100%	A second medical opinion by an appropriate specialist or surgeon.
Telemedicine	No Charge after deductible	100%	Members have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use, accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones. MDLIVE does not replace a members physician - rather it is another option to receive care for acute, non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care or emergency room visits. Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.
Family Planning Services	No Charge	100%	Counseling on the use of contraceptives, sterilization procedures, and related topics.
Transplant	0% Coinsurance after deductible	100%	Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.
Acupuncture	0% Coinsurance after deductible	100%
Chemotherapy	0% Coinsurance after deductible	100%	Chemotherapy in an outpatient facility or in a Health Care Professional's office. Orally-administered anti-cancer drugs are covered under the prescription drug benefit.
Diabetic Equipment and Supplies	0% Coinsurance after deductible	100%

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Skilled Nursing Facility	0% Coinsurance after deductible	100%	A facility that performs skilled nursing care and rehabilitation services provided on a continuous, daily basis.
Inpatient Hospital Services (e.g., Hospital Stay)	0% Coinsurance after deductible	100%	Health care you get when you're admitted as a patient to a health care facility, like a hospital or skilled nursing facility.
Inpatient Physician and Surgical Services	0% Coinsurance after deductible	100%	Surgical services performed by a physician or surgeon in an inpatient facility.
Delivery and All Inpatient Services for Maternity Care	0% Coinsurance after deductible	100%	Delivery and inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Specialist Visit	0% Coinsurance after deductible	100%	Visits to a physician to diagnose, manage, prevent or treat certain types of symptoms and conditions related to a specific disease or condition.
Home Health Care Services	0% Coinsurance after deductible	100%	Each visit of up to four hours by a home health aide is one visit.
Other Practitioner Office Visit (Nurse, Physician Assistant)	0% Coinsurance after deductible	100%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	0% Coinsurance after deductible	100%
Outpatient Surgery Physician/Surgical Services	0% Coinsurance after deductible	100%	Surgical services performed by a physician or surgeon in an outpatient facility.
Primary Care Visit to Treat an Injury or Illness	0% Coinsurance after deductible	100%	Visit to a clinician for health services that cover a range of prevention, wellness, and treatment for common illnesses.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Specialty Drugs	Not Applicable	Not Applicable	Specialty drugs are used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. The drugs are often self-injected or administered in a physician's office or through home health services.
Generic Drugs	0% Coinsurance after deductible	100%	A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.
Non-Preferred Brand Drugs	0% Coinsurance after deductible	100%	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Non-preferred drugs may or may not be included on a plan's covered drug list or formulary and have higher cost-share.
Preferred Brand Drugs	0% Coinsurance after deductible	100%	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Preferred drugs are included on a plan's covered drug list or formulary.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Substance Abuse Disorder Inpatient Services	0% Coinsurance after deductible	100%	Diagnosis and treatment of alcoholism and/or substance use and/or dependency in an inpatient setting. This includes coverage for detoxification and/or rehabilitation services as a consequence of chemical use and/or substance use.
Substance Abuse Disorder Outpatient Services	0% Coinsurance after deductible	100%	Also includes 20 visits per year for family counseling.
Mental/Behavioral Health Inpatient Services	0% Coinsurance after deductible	100%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Mental/Behavioral Health Outpatient Services	0% Coinsurance after deductible	100%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an outpatient setting.
Applied Behavior Analysis Based Therapies	0% Coinsurance after deductible	100%	Design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Urgent Care Centers or Facilities	0% Coinsurance after deductible	100%	A licensed facility (except Hospitals) that provides care for an illness, injury or condition serious enough to require care right away, but not so severe as to require emergency room care.
Emergency Transportation/Ambulance	0% Coinsurance after deductible	0% Coinsurance after deductible	Ambulance services for an emergency medical condition.
Emergency Room Services	0% Coinsurance after deductible	0% Coinsurance after deductible	Healthcare services you get in an emergency room.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Well Baby Visits and Care	No Charge	100%	Routine doctor visits for comprehensive preventive health services that occur when a baby is young.
Prenatal and Postnatal Care	No Charge	100%	Healthcare for expectant mothers before and after the birth of their child.
Preventive Care/Screening/Immunization	No Charge	100%	Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Gym Membership Reimbursement	$0	$0	Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse
Eating Disorder Treatment	Not Applicable	Not Applicable

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
X-rays and Diagnostic Imaging	0% Coinsurance after deductible	100%	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Imaging (CT/PET Scans, MRIs)	0% Coinsurance after deductible	100%	Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition
Laboratory Outpatient and Professional Services	0% Coinsurance after deductible	100%	Professional fees and services associated with laboratory work for diagnostic and treatment purposes.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Routine Dental Services (Adult)	0% Coinsurance after deductible	100%	Routine Dental Care (exams, x-rays and fillings), One dental exam and cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.
Basic Dental Care - Adult	0% Coinsurance after deductible	100%	Preventive dental coverage for procedures which help prevent oral disease from occurring, including but not limited to, prophylaxis (scaling and polishing teeth at 6-month intervals).

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Major Dental Care - Child	0% Coinsurance after deductible	100%	Services, including procedures for treatment of diseased pulp chambers and pulp canals, where Hospitalization is not required, removable complete or partial dentures, including six (6) months follow-up care; and additional services include insertion of identification slips, repairs, relines and rebases and treatment of cleft palate.
Orthodontia - Child	0% Coinsurance after deductible	100%	Orthodontics used to help restore oral structures to health and function and to treat serious medical conditions for children.
Basic Dental Care - Child	0% Coinsurance after deductible	100%	Routine dental examinations, visits and services for children performed in a dentist's office covered once within 6 month consecutive period.
Dental Check-Up for Children	0% Coinsurance after deductible	100%	Procedures which help prevent oral disease from occurring.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Prosthetic Devices	0% Coinsurance after deductible	100%	1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).
Inpatient Rehabilitation Services	0% Coinsurance after deductible	100%	60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.
Outpatient Rehabilitation Services	0% Coinsurance after deductible	100%	60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.
Chiropractic Care	0% Coinsurance after deductible	100%	Care performed by a Doctor of Chiropractic (Chiropractor).
Durable Medical Equipment	0% Coinsurance after deductible	100%	Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

		Bronze Secure Plus 3 NS INN Excellus BCBS EPO Adult/Family Dental Dep25 Acupuncture

You Pay

$0.00

Price Per Month	$394.86	Metal	Bronze	Overall Quality Rating
Quality Measure	Plan Administration	Rating		Description	Based on certain measures of how well a plan is run, including customer service, access to needed information, and network providers ordering appropriate testing and treatment.
Quality Measure	Member Experience	Rating		Description	Based on member satisfaction surveys about their health care, doctors, and ease of getting appointments and services.
Quality Measure	Medical Care	Rating		Description	Based on the plan's network providers improving or maintaining the health of its members with regular screenings, tests, vaccines, and monitoring of some conditions.
Maximum Out of Pocket	$8700 / $8700 per person \| $17400 per group	Out-of-Network Coverage	No	Allows Health Savings Account	No
Plan Id	78124NY0900023	Persons Covered	individual	Deductible	$8700 / $8700 per person \| $17400 per group
Specialist(s) Referral Required	No

Design	Free preventive care and flu shots. Telemedicine services covered at no cost after your deductible is met. Your first 3 visits to your Primary Care Physician are covered in full and are not subject to the deductible. No referrals needed, and no need to identify a Primary Care Physician. Coverage for services in network only with access to 100% of local hospitals and 99% of doctors throughout 31 counties in New York State. If you are traveling, BlueCard provides access to doctors and hospitals in the US, Canada & Mexico. Get paid up to $600 for working out with our ExerciseRewards Program; a gym and fitness class reward program. Access to healthy perks including a 24/7 Nurse Call Line and Blue365 discounts on fitness gear, weight loss programs, dental services and more. This plan has an embedded deductible and out of pocket maximum.

Design

Adult Vision Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Routine Eye Exam (Adult)	0% Coinsurance after deductible	100%

Pediatric Vision

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Routine Eye Exam for Children	0% Coinsurance after deductible	100%	Emergency, preventive and routine vision care for children.
Contact Lenses for Children	0% Coinsurance after deductible	100%	One prescribed lenses and frames in a 12-month period.
Eye Glasses for Children	0% Coinsurance after deductible	100%	One prescribed lenses and frames in a 12-month period.

Other Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Second Opinion	0% Coinsurance after deductible	100%	A second medical opinion by an appropriate specialist or surgeon.
Telemedicine	No Charge after deductible	100%	Members have access to MDLIVEs vast network of Board-Certified doctors for non-emergency care. The system is easy to use, accessible through a toll-free phone number, video conferencing via the Web, or a secure mobile app available for smartphones. MDLIVE does not replace a members physician - rather it is another option to receive care for acute, non-life threatening conditions when a doctor is unavailable or serves as an alternative to urgent care or emergency room visits. Using MDLIVE may result in a lower member cost share. Please consult the subscriber contract for more information.
Family Planning Services	No Charge	100%	Counseling on the use of contraceptives, sterilization procedures, and related topics.
Transplant	0% Coinsurance after deductible	100%	Transplants determined to be nonexperimental and non-investigational are covered, including but not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.
Acupuncture	0% Coinsurance after deductible	100%
Chemotherapy	0% Coinsurance after deductible	100%	Chemotherapy in an outpatient facility or in a Health Care Professional's office. Orally-administered anti-cancer drugs are covered under the prescription drug benefit.
Diabetic Equipment and Supplies	0% Coinsurance after deductible	100%

Hospitalization

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Skilled Nursing Facility	0% Coinsurance after deductible	100%	A facility that performs skilled nursing care and rehabilitation services provided on a continuous, daily basis.
Inpatient Hospital Services (e.g., Hospital Stay)	0% Coinsurance after deductible	100%	Health care you get when you're admitted as a patient to a health care facility, like a hospital or skilled nursing facility.
Inpatient Physician and Surgical Services	0% Coinsurance after deductible	100%	Surgical services performed by a physician or surgeon in an inpatient facility.
Delivery and All Inpatient Services for Maternity Care	0% Coinsurance after deductible	100%	Delivery and inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery.

Outpatient Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Specialist Visit	0% Coinsurance after deductible	100%	Visits to a physician to diagnose, manage, prevent or treat certain types of symptoms and conditions related to a specific disease or condition.
Home Health Care Services	0% Coinsurance after deductible	100%	Each visit of up to four hours by a home health aide is one visit.
Other Practitioner Office Visit (Nurse, Physician Assistant)	0% Coinsurance after deductible	100%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	0% Coinsurance after deductible	100%
Outpatient Surgery Physician/Surgical Services	0% Coinsurance after deductible	100%	Surgical services performed by a physician or surgeon in an outpatient facility.
Primary Care Visit to Treat an Injury or Illness	0% Coinsurance after deductible	100%	Visit to a clinician for health services that cover a range of prevention, wellness, and treatment for common illnesses.

Prescription Drugs

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Specialty Drugs	Not Applicable	Not Applicable	Specialty drugs are used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. The drugs are often self-injected or administered in a physician's office or through home health services.
Generic Drugs	0% Coinsurance after deductible	100%	A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.
Non-Preferred Brand Drugs	0% Coinsurance after deductible	100%	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Non-preferred drugs may or may not be included on a plan's covered drug list or formulary and have higher cost-share.
Preferred Brand Drugs	0% Coinsurance after deductible	100%	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Preferred drugs are included on a plan's covered drug list or formulary.

Mental Health and Substance Abuse Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Substance Abuse Disorder Inpatient Services	0% Coinsurance after deductible	100%	Diagnosis and treatment of alcoholism and/or substance use and/or dependency in an inpatient setting. This includes coverage for detoxification and/or rehabilitation services as a consequence of chemical use and/or substance use.
Substance Abuse Disorder Outpatient Services	0% Coinsurance after deductible	100%	Also includes 20 visits per year for family counseling.
Mental/Behavioral Health Inpatient Services	0% Coinsurance after deductible	100%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Mental/Behavioral Health Outpatient Services	0% Coinsurance after deductible	100%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an outpatient setting.
Applied Behavior Analysis Based Therapies	0% Coinsurance after deductible	100%	Design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis

Emergency Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Urgent Care Centers or Facilities	0% Coinsurance after deductible	100%	A licensed facility (except Hospitals) that provides care for an illness, injury or condition serious enough to require care right away, but not so severe as to require emergency room care.
Emergency Transportation/Ambulance	0% Coinsurance after deductible	0% Coinsurance after deductible	Ambulance services for an emergency medical condition.
Emergency Room Services	0% Coinsurance after deductible	0% Coinsurance after deductible	Healthcare services you get in an emergency room.

Preventive and Wellness Services and Chronic Disease Management

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Well Baby Visits and Care	No Charge	100%	Routine doctor visits for comprehensive preventive health services that occur when a baby is young.
Prenatal and Postnatal Care	No Charge	100%	Healthcare for expectant mothers before and after the birth of their child.
Preventive Care/Screening/Immunization	No Charge	100%	Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Gym Membership Reimbursement	$0	$0	Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse
Eating Disorder Treatment	Not Applicable	Not Applicable

Laboratory Outpatient and Professional Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
X-rays and Diagnostic Imaging	0% Coinsurance after deductible	100%	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Imaging (CT/PET Scans, MRIs)	0% Coinsurance after deductible	100%	Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition
Laboratory Outpatient and Professional Services	0% Coinsurance after deductible	100%	Professional fees and services associated with laboratory work for diagnostic and treatment purposes.

Adult Dental Care

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Routine Dental Services (Adult)	0% Coinsurance after deductible	100%	Routine Dental Care (exams, x-rays and fillings), One dental exam and cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.
Basic Dental Care - Adult	0% Coinsurance after deductible	100%	Preventive dental coverage for procedures which help prevent oral disease from occurring, including but not limited to, prophylaxis (scaling and polishing teeth at 6-month intervals).

Pediatric Dental Care

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Major Dental Care - Child	0% Coinsurance after deductible	100%	Services, including procedures for treatment of diseased pulp chambers and pulp canals, where Hospitalization is not required, removable complete or partial dentures, including six (6) months follow-up care; and additional services include insertion of identification slips, repairs, relines and rebases and treatment of cleft palate.
Orthodontia - Child	0% Coinsurance after deductible	100%	Orthodontics used to help restore oral structures to health and function and to treat serious medical conditions for children.
Basic Dental Care - Child	0% Coinsurance after deductible	100%	Routine dental examinations, visits and services for children performed in a dentist's office covered once within 6 month consecutive period.
Dental Check-Up for Children	0% Coinsurance after deductible	100%	Procedures which help prevent oral disease from occurring.

Rehabilitative and Habilitative Services and Devices

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Prosthetic Devices	0% Coinsurance after deductible	100%	1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).
Inpatient Rehabilitation Services	0% Coinsurance after deductible	100%	60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.
Outpatient Rehabilitation Services	0% Coinsurance after deductible	100%	60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.
Chiropractic Care	0% Coinsurance after deductible	100%	Care performed by a Doctor of Chiropractic (Chiropractor).
Durable Medical Equipment	0% Coinsurance after deductible	100%	Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

Plan Documents

Customer Service	www.excellusbcbs.com
Summary of Benefits and Coverage	https://www.excellusbcbs.com/sbc-finder?PlanId=78124NY0900023-01_CoveragePeriodStart=01/01/2022
Prescription Drug List	https://www.excellusbcbs.com/plans/individual/drug-list
Provider Network	https://www.excellusbcbs.com/find-a-doctor/provider
Plan Brochure	https://www.excellusbcbs.com/findaplan
Payment Information	https://www.excellusbcbs.com/nysoh-premium-payment

Plan Details