Excellent Health Plan Member Name: Veronica Casto Member ID:…

Excellent Health Plan Member Name: Veronica Casto Member ID: MKJ538721P   Prescription Group No: W32187 RX Group: 321543   Generic RX $15 Preferred Name brand RX $50 Nonpreferred Name brand RX $70 Unknown State University Prime Care Excellence – HMO   Date Issued 04/01/XXXX   In-Network Member Responsibility Primary               $25.00 Specialist            $50.00 PT/OT/SP           $35.00 BH, SU               $100.00 Urgent Care        $50.00 ED                      $150.00   Veronica went to the general physician. This was a follow-up visit for hypertension that has been active for the past five years. What copayment should the physician’s office collect?