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SimplyBlue Plus Bronze 5
TJQ8
Bronze
HSA Eligible
Premium Rates
Single
$834.43
Subscriber & Spouse
$1,668.85
Subscriber & Child(ren)
$1,418.53
Family
$2,378.11
Plan Information
Plan Type
Deductible HSA
Metal Level
Bronze
Effective Date
01/01/2026 - 03/31/2026
Rating Region
Rochester
Deductibles (In-Network)
Individual
$6,000
Family
$12,000
Deductibles (Out-of-Network)
Individual
$10,000
Family
$20,000
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
$40 copay subject to deductible
Specialist Office Visit
$60 copay subject to deductible
ER Copay
$500 copay subject to deductible
Urgent Care Copay
$60 copay subject to deductible
Coinsurance (In-Network)
100%
Coinsurance (Out-of-Network)
100%
Prescription Drug Coverage
$10/$45/$90 subject to deductible