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SimplyBlue Plus Gold 17
TJV6
Gold
Not HSA Eligible
Premium Rates
Single
$1,175.81
Subscriber & Spouse
$2,351.61
Subscriber & Child(ren)
$1,998.87
Family
$3,351.05
Plan Information
Plan Type
Hybrid
Metal Level
Gold
Effective Date
01/01/2026 - 03/31/2026
Rating Region
Rochester
Deductibles (In-Network)
Individual
$1,100
Family
$2,200
Deductibles (Out-of-Network)
Individual
$5,000
Family
$10,000
Out of Pocket Max (In-Network)
Individual
$8,250
Family
$16,500
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
$300 copay
Urgent Care Copay
$70 copay
Coinsurance (In-Network)
80%
Coinsurance (Out-of-Network)
60%
Prescription Drug Coverage
$10/$45/$90 (no deductible)