AMBULANCE 
Ambulance $290  copay per date of service $290  copay per date of service 
TRANSPORTATION 
N/A Not covered Not covered 
MEDICARE PART BDRUGS 
Chemotherapy drugs 20% of the cost 20% of the cost 
Other Part Bdrugs 20% of the cost 20% of the cost H5216324000SB23 Summary of Benefits 13 H5216324000 
Prescription Drug Benefits 
PRESCRIPTION DRUGS 
Important Message About What You Pay for Vaccines