Outpatient Lab: $20 Copay X-rays: $20 Copay Outpatient Surgery Physician/Surgical Services: $0 Copay after deductible Outpatient Facility Fee: $250 Copay after deductible
Generic Drugs: $20 Copay Preferred Brand Drugs: $50 Copay Non-Preferred Brand Drugs: $75 Copay Specialty Drugs: $75 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) Office Visit for Primary Doctor Find Doctors
