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PPO Select® Choice Series III

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

Get Started!

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.

Copyright 2007. Health Care Service Corporation. All Rights Reserved.
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