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For Employers Comparison Chart   30261 30262 30263 30264 30265 Network Deductible & Copayments Network Deductible N/A N/A N/A N/A N/A Office Visit Copay $10 $15 $15 $20 $25 Prescription Drug Copay $7/$15 /$30 $7/$15 /$30 $10/$20 /$30 $10/$20 /$30 $10/$30 /$50 Inpatient Hospital Copay/Coinsurance $0 10%1 20%1 20%2 30%3 Outpatient Surgery Copay/Coinsurance $0 $0 20%1 20%2 30%3 Outpatient Lab & X-ray Copay/Coinsurance $0 $0 $0 $0 $0 Urgent Care Facility Copay/Coinsurance $30 $30 $35 $50 $50 Emergency Room Copay/Coinsurance $60 $60 $100 $100 $150   Non-Network Deductible & Coinsurance Non-Network Deductible N/A N/A N/A N/A N/A Non-Network Coinsurance N/A N/A N/A N/A N/A

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