PPO Select Value® CareSM

Policy Form Number: PPO-IND-VALUE

Office Setting Services If using network providers PPO Select Value Care pays

Physician Services

Routine Physical Examinations
Well Child Care
Hemoccult Tests
Pap Smears
Immunizations 8 years and over
Routine lab
X-ray
Annual Routine Vision and Hearing Exams
(Routine mammograms, colorectal cancer screening and prostate cancer screenings are not subject to the $300 maximum)


50% of Allowable Amount


$300 Calendar Year Maximum per participant


Individual & Family Plans Only

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