Back to Rate Plans
SimplyBlue Plus Gold 14
TJK4
Gold
Not HSA Eligible
Premium Rates
Single
$1,158.23
Subscriber & Spouse
$2,316.45
Subscriber & Child(ren)
$1,968.99
Family
$3,300.94
Plan Information
Plan Type
Hybrid
Metal Level
Gold
Effective Date
01/01/2026 - 03/31/2026
Rating Region
Rochester
Deductibles (In-Network)
Individual
$1,400
Family
$2,800
Deductibles (Out-of-Network)
Individual
$5,000
Family
$10,000
Out of Pocket Max (In-Network)
Individual
$7,500
Family
$15,000
Out of Pocket Max (Out-of-Network)
Individual
$10,000
Family
$20,000
Copays & Coinsurance
PCP Office Visit
$25 copay subject to deductible
Specialist Office Visit
$40 copay subject to deductible
ER Copay
$450 copay subject to deductible
Urgent Care Copay
$40 copay subject to deductible
Coinsurance (In-Network)
80%
Coinsurance (Out-of-Network)
60%
Prescription Drug Coverage
$5/$35/$70 (no deductible)