PPO plans have in-network and out-of-network coverage for most services. The out-of-network annual deductible and out-of-pocket maximum are double the in-network amount. The amounts listed below apply for in-network services only.

Community Blue PPO Plan options breakdown
Community Blue PPO
Plan options
Platinum $0 Platinum $250 Platinum $500 Gold $1,500
Annual deductible
(individual / family)
$0 / $0 $250 / $500 $500/$1,000 $1,500 / $3,000
Coinsurance Percentage 20% 20% 10% 20%
Embedded
Coinsurance Maximum

(individual / family)
$1,500 / $3,000 $500 / $1,000 $500 / $1,000 $4,500 / $9,000
Out-of-pocket maximum
(individual / family)
$6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $8,150 / $16,300
PCP office visit copays $20 $20 $20 $30
Preferred generic pharmacy copays $10 $10 $5 $10

Find more details about this plan in the Community Blue Group Benefits Certificate (PDF).