Physical therapy  Covered Covered 
Prescription drugs –Medicare 
Part Bdrugs Covered Covered 
Prescription drugs –outpatient 
prescription drugs; Medicare 
covered &non-Medicare 
covered Covered Covered 
Preventive care (e.g., flu 
vaccine, diabetic screenings) Covered Covered 
Routine non-emergency medical 
transportation  Covered Covered 
Skilled nursing facility  Covered Covered 
Urgently needed services  Covered Covered H5619075000SB23 Summary of Benefits 15 H5619075000 
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