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Specialist: $** Copay

Rx(Generic/Brand): $*/$** Copay

Urgent Care: $5 Copay

ER: 25% Coinsurance

Ambetterhealth.com/copays Max Out-of-Pocket: $1,700

Plan: CMS Standard Silver RXBIN: 004336

Bronze Silver Gold Network Coverage Only RXPCN: ADV

RXGROUP: RX5453

REFERRAL FROM PCP NOT...