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.

Simply Blue PPO Plan options breakdown
Simply Blue PPO
Plan options
Platinum
$250
Gold
$500
Gold $1,000 Gold $1,500 Silver $2,000 Silver $2,500 Silver $3,000 Silver $4,000
Annual deductible
(individual / family)
$250 /
$500
$500 / $1,000 $1,000 / $2,000 $1,500 / $3,000 $2,000 / $4,000 $2,500 / $5,000 $3,000 / $6,000 $4,000 / $8,000
Coinsurance Percentage 20% 20% 20% 20% 20% 30% 20% 30%
Embedded
Coinsurance Maximum

(individual / family)
$1,000 /
$2,000
$3,000 / $6,000 $2,000 / $4,000 $1,000 / $2,000 N/A N/A N/A N/A
Out-of-pocket maximum
(individual / family)
$6,600 /
$13,200
$6,600 / $13,200 $6,600 / $13,200 $6,600 / $13,200 $7,350 / $14,700 $7,350 / $14,700 $7,350 / $14,700 $7,350 / $14,700
Office visit copays
$20 $20 $20 $20 $30 $40 $30 $30
Pharmacy copays
$10 $15 $15 $15 $15 $25 $30 $20

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

Certificates are legal documents that describe the benefits of a health insurance plan. Your plan might have different benefits and limitations than those listed in this document.