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SimplyBlue Plus Gold 5
TIZ2
Gold
Not HSA Eligible
Premium Rates
Single
$1,216.57
Subscriber & Spouse
$2,433.14
Subscriber & Child(ren)
$2,068.18
Family
$3,467.23
Plan Information
Plan Type
Copay
Metal Level
Gold
Effective Date
01/01/2026 - 03/31/2026
Rating Region
Rochester
Deductibles (In-Network)
Individual
None
Family
None
Deductibles (Out-of-Network)
Individual
$5,000
Family
$10,000
Out of Pocket Max (In-Network)
Individual
$9,200
Family
$18,400
Out of Pocket Max (Out-of-Network)
Individual
$10,000
Family
$20,000
Copays & Coinsurance
PCP Office Visit
$40 copay
Specialist Office Visit
$70 copay
ER Copay
$650 copay
Urgent Care Copay
$70 copay
Coinsurance (In-Network)
None
Coinsurance (Out-of-Network)
80%
Prescription Drug Coverage
$15/40%/50%