| Benefit Summary | Summary of Benefits & Coverage | Prescription Plan* |
| Classic Blue 100/200 (3T7) | Classic Blue 100/200 (3T7) | $5/20/35 Retail $10/40/70 Mail |
| Platinum Plan | Platinum Plan | $5/35/70 Retail $10/70/140 Mail |
| PPO $10/ $35 (3T7) | PPO $10/ $35 (3T7) | $5/20/35 Retail $10/40/70 Mail |
| Medicare Supplement MS4 | $15/30/45 Retail $30/60/90 Mail |
*Prescription Plan is linked to Drug Formulary
* To view Participating Providers and your subscriber information please sign on to your Excellus account
