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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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PPO Plans


Rx Option B Plans – Benefit Summaries (effective 1/1/2014)

PPO5 500 100 6.3K B 
PPO5 500 90 3.3K B 
PPO5 500 90 B 
PPO5 500 80 2.5K B 
PPO5 500 80 B 
PPO5 1K 100 6.3K B 
PPO5 1K 90 5.9K B 
PPO5 1K 90 B 
PPO5 1K 80 4.7K B 
PPO5 1K 80 B 
PPO5 1.5K 100 6.3K B 
PPO5 1.5K 90 B 
PPO5 1.5K 80 B 
PPO5 2K 100 6.3K B 
PPO5 2.5K 100 6.3K B 
PPO5 2.5K 100 B 
PPO5 2.5K 80 B 
PPO5 3.5K 100 6.3K B 
PPO5 3.5K 100 B 
PPO5 3.5K 80 B 
PPO5 3.5K 70 B 
PPO5 5K 100 6.3K B 
PPO5 5K 100 B 
PPO5 5K 80 B 
PPO5 5K 70 B 
PPO5 6.3K 100 B 
2PPO5 500 100 B 
2PPO5 500 90 B 
2PPO5 500 80 B 
2PPO5 1K 100 B 
2PPO5 1K 90 B 
2PPO5 1K 80 B 
2PPO5 1.5K 100 B 
2PPO5 1.5K 90 B 
2PPO5 1.5K 80 B 
2PPO5 2K 100 B 
PPO9 2.5K 80 B  
PPO9 3.5K 80 B  
PPO9 5K 80 B  
PPO9 6.3K 100 B  
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