PPO Select Value® CareSM

Policy Form Number: PPO-IND-VALUE

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

Individual & Family Plans Only

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