Excellent Health Plan

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 $70Unknown 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 had bronchitis for the past eight days. Feeling miserable, she went to the local hospital’s Emergency Department for care. She received a prescription for antibiotics. What co-payment should the hospital collect?$50.00$100.00$150.00Cannot be determined