| Benefit Summary | Summary of Benefits & Coverage | Prescription Plan* |
|---|---|---|
| PPO $15/ $35 (3T10) | PPO $15/ $35 (3T10) | $ 15/30/45 Retail $ 30/60/90 Mail |
*Prescription Plan: Drug Formulary
* To view Participating Providers and your subscriber information please sign on to your Excellus account