Outpatient hospital coverage •Outpatient surgery at Outpatient Hospital:  $250 copay 
•Outpatient surgery at Ambulatory Surgical Center:   $200 copay 
Doctor visits •Primary care provider:  $0 copay 
•Specialist:  $15 copay You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs 
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please