Co-Pay Amount CoPay 5 $5.00 CoPay 10 $10.00 CoPay 15 $15.00 CoPay 20 $20.00 CoPay 25 $25.00 CoPay 35 $35.00 Pay 65 $65.00 Pay 85 $85.00 Pay 175 $175.00 Pay 250 $250.00 Tax field is really loss of Discount for Cash
