PPO Select Value® CareSM
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 | $200 | $10 | $30 | $45 | $3,000 |
| Plan IIII | |||||
