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 
Our plan covers most Part Dvaccines at no cost to you, no matter what cost-sharing tier it’s on ,even if 
you haven’t paid your deductible .
Important Message About What You Pay for Insulin 
You won’t pay more than $35 for aone-month (up to 30-day) supply of each Part Dinsulin product