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

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Healthy Support PPO Plans

PW_E225463

Rx Option D Plans – Benefit Summaries (effective 1/1/2015)

VPPO14 1.5K/20 
VPPO14 3K/20 
VPPO14 5K/0 6.6K 
VPPO14 5K/0 
PPO14 1.5K 20 D 
PPO14 3K 20 D 
PPO14 5K 0 6.6K D 
PPO14 5K 0 D 
 
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