Form 5500 · Employee benefit plan · ROCHESTER, NY
EXCELLUS HEALTH PLAN INC
The filing calls this plan EXCELLUS HEALTH AND WELFARE PLAN.
Public Form 5500 records show how EXCELLUS HEALTH PLAN INC of ROCHESTER, NY, a finance and insurance employer, structures its employee benefits. Coverage is written through EXCELLUS BLUE CROSS BLUE SHIELD. The plan's most recent policy period ended in December.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 15-0329043 · plan 502 · plan year 2024, filed Jul 30, 2025
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How this plan is funded
Both, as reported
The medical insurance contracts on the filing cover fewer than half the people in the plan, so the rest is paid another way.
A stop-loss policy appears on a Form 5500 only when the plan itself is the beneficiary, or the premiums are paid from plan money. Many employers buy stop-loss and never report it here. So a plan with no stop-loss on its filing may still have it.
Benefits declared on this filing
Also declared: other welfare.
Declared benefits are the plan’s own line 8b codes on Form 5500. “Not on Schedule A” means no insured contract for that line appears on this filing. That usually means the benefit is self-funded, or it sits under a different plan number.
Where a line has more than one insured contract, the carrier and the covered figure are the largest contract's by premium. The contracts are not added up: a pharmacy carve-out and the medical carrier beside it cover the same people.
Persons covered is the count the carrier filed for that policy at the end of its policy year, and it can include dependents. Participants is the plan's own count at the start of its plan year. The two count different people, so a covered figure can be larger.
Plan brief
All 3 insured contracts are health coverage with EXCELLUS BLUE CROSS BLUE SHIELD.
The filing declares health and dental. Dental appears with no insured contract on Schedule A. That coverage may be self-funded, or placed with a carrier that is not on this filing.
Reported premium is $4,875,163; the filing discloses no broker commission on these contracts.
The most recent policy period ended in December, and the plan year ends December 31. Group contracts typically renew on that annual cycle.
No broker of record is named on the Schedule A. The contracts may be written directly with the carrier, or the broker fields were left blank on the filing.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| EXCELLUS BLUE CROSS BLUE SHIELD | Health | 1,390 | Jan 1, 2025 | $3,914,383 | $0 |
| EXCELLUS BLUE CROSS BLUE SHIELD | Health | 185 | Jan 1, 2025 | $553,840 | $0 |
| EXCELLUS BLUE CROSS BLUE SHIELD | Health | 137 | Jan 1, 2025 | $406,940 | $0 |
Covered = persons covered at policy year end, as filed on Schedule A for that policy — often certificates or one class, not the whole plan. Premium = the filing’s own premium/charges figure; “—” means not credibly reported.
Administrator and service providers
The plan administrator is from line 3a of the main form. We publish company names only.
Other plans filed by this employer
How this plan compares
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