| Benefit Summary | Summary of Benefits & Coverage | Prescription Plan* |
|---|---|---|
| Gold Plan | Gold Plan | $ 5/35/70 Retail After Deductible $10/70/140 Mail After Deductible |
| PPO $10/ $100 (3T3) | PPO $10/ $100 (3T3) | $ 5/10/25 Retail $10/20/50 Mail |
| Medicare Supplement MS3 | $10/25/40 Retail $20/50/80 Mail |
*Prescription Plan is linked to Drug Formulary
* To view Participating Providers and your subscriber information please sign on to your Excellus account