$196 copay per day for days 
21-100 $0 copay per day for days 1-20 
$196 copay per day for days 
21-100 
PHYSICAL THERAPY 
Cost share may vary depending 
on the service and where service 
is provided. $20 to  $30 copay $20 to  $30 copay 
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