Physical Therapy  •$15 copay 
ADDITIONAL BENEFITS 
Ambulance $270  copay per date of service 
Transportation $0 copay for plan approved location up to 48 one-way trip(s) per year. 
This benefit is not to exceed 25 miles per trip. 
The member  must  contact transportation vendor to arrange 
transportation and should contact Customer Care to be directed to 
their plan's specific transportation provider. 
Medicare Part Bdrugs •Chemotherapy drugs:  19% of the cost