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

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Healthy Support Open Access POS Plans

PW_E240490

Rx Option D Plans – Benefit Summaries (effective 1/1/2016)

Fully Insured Groups 
VOAP14 1.5K 20 D 
VOAP14 3K 20 D 
VOAP14 5K 0 D 
VOAP14 5K 0 6.6K D 
OAP14 1 5K 20 D 
OAP14 3K 20 D 
OAP14 5K 0 D 
OAP14 5K 0 6.6K D 
 
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