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SimplyBlue Plus Gold 21
TKG8
Gold
HSA Eligible
Premium Rates
Single
$1,129.90
Subscriber & Spouse
$2,259.80
Subscriber & Child(ren)
$1,920.83
Family
$3,220.21
Plan Information
Plan Type
Deductible HSA
Metal Level
Gold
Effective Date
01/01/2026 - 03/31/2026
Rating Region
Rochester
Deductibles (In-Network)
Individual
$2,000
Family
$4,000
Deductibles (Out-of-Network)
Individual
$5,000
Family
$10,000
Out of Pocket Max (In-Network)
Individual
$5,500
Family
$11,000
Out of Pocket Max (Out-of-Network)
Individual
$10,000
Family
$20,000
Copays & Coinsurance
PCP Office Visit
$10/$25 copay subject to deductible
Specialist Office Visit
$40 copay subject to deductible
ER Copay
$150 copay subject to deductible
Urgent Care Copay
$40 copay subject to deductible
Coinsurance (In-Network)
100%
Coinsurance (Out-of-Network)
60%
Prescription Drug Coverage
$5/$45/$90 subject to deductible