Outpatient surgery at 
ambulatory surgical center $250 copay $250 copay 
DOCTOR OFFICE VISITS 
Primary care provider (PCP) $0 copay $0 copay 
Specialists $30 copay $30 copay 
PREVENTIVE CARE 
N/A Our plan covers many preventive  
services at no cost when you see  
an in-network provider including: 
•Abdominal aortic aneurysm  
screening $0 copay  
Any additional preventive services  
approved by Medicare during the