| Prescription Drugs |
| Options |
Separate
Deductibles
|
Prescription Drug Card Program
|
| |
Individual
(per calendar year)
|
Copayment Amounts
|
Calendar Year Maximum Benefits
|
Generic
|
Preferred
|
Non Preferred
|
| Plan I |
$200
|
$10
|
$30
|
$45
|
$3,000
|
| Plan II |
| Plan III |
$200
|
$10
|
$30
|
$45
|
$3,000
|
| Plan IV |
| Plan V |
$200
|
$10
|
$30
|
$45
|
$3,000
|
| Plan VI |
| Plan VII |
$200
|
$10
|
$30
|
$45
|
$3,000
|
| Plan VIII |
* Texas Department of Insurance Form: PPO-SELCHOICE-3-OLC-2
|
