| Benefit Summary | Summary of Benefits & Coverage | Prescription Plan* |
|---|---|---|
| PPO $10/35 (3T6) | PPO $10/35 (3T6) | $5/15/30 Retail After Deductible $10/30/60 Mail After Deductible |
| Gold Plan | Gold Plan | $5/35/70 Retail After Deductible $10/70/140 Mail After Deductible |
| 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
