PPO Select BasicSM
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 | $500 | $10 | $50 | $65 | $2,500 |
| Plan II | $500 | $10 | $50 | $65 | $2,500 |
| Plan IIII | |||||
| Plan IV | $500 | $10 | $50 | $65 | $2,500 |
* Separate deductible of $500 not applicable to Generic drugs, but will be applicable to Preferred and Non-preferred drugs.
