SimplyBlue Plus Guaranteed Issue

Select Plan to Review

*RX Coverage: Generic/Preferred Brand/Non-Preferred Brand Copay.

When you click on one of the View buttons below your Summary of Benefits and Coverage (SBC) will pull up in PDF format.

  Plan Number Network Maternity In-Network Deductible Amount Primary Care Practitioner/Specialist Copay Coinsurance Percent Out-of-Pocket Maximum RX Coverage*
View T4 S No $1500 Individual/$3000 Family $30 Copay for First 2 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible 20% $6500 Individual/$13000 Family Generic Only
View T5 S No $2500 Individual/$3000 Family $30 Copay for First 2 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible 20% $7500 Individual / $15000 Family Generic Only
View T6 S No $3500 Individual/$7000 Family $30 Copay for First 2 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible 20% $8500 Individual/$17000 Family Generic Only