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

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PPO Plans

PW_G323310
 

Rx Option B Plans – Benefit Summaries (effective 6/1/2012)

PPO5 500/100 B 
PPO5 500/90 B 
PPO5 500/80 B 
PPO5 1K/90 B 
PPO5 1K/80 B 
PPO5 1.5K/90 B 
PPO5 1.5K/80 B 
PPO5 2.5K/100 B 
PPO5 2.5K/80 B 
PPO5 3.5K/100 B 
PPO5 3.5K/80 B 
PPO5 3.5K/70 B 
PPO5 5K/100 B 
PPO5 5K/80 B 
PPO5 5K/70 B 
PPO5 10K/100 B 
PPO9 2.5K/80 B 
PPO9 3.5K/80 B 
PPO9 5K/80 B 
PPO9 10K/100 B 
 
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