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SimplyBlue Plus Gold 19
TJY8
Gold
Not HSA Eligible
Premium Rates
Single
$1,122.75
Subscriber & Spouse
$2,245.50
Subscriber & Child(ren)
$1,908.67
Family
$3,199.83
Plan Information
Plan Type
Hybrid
Metal Level
Gold
Effective Date
01/01/2026 - 03/31/2026
Rating Region
Rochester
Deductibles (In-Network)
Individual
$2,500
Family
$5,000
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
$40 copay
Specialist Office Visit
$60 copay
ER Copay
$350 copay
Urgent Care Copay
$60 copay
Coinsurance (In-Network)
80%
Coinsurance (Out-of-Network)
60%
Prescription Drug Coverage
$5/$45/$90 (no deductible)