•$150 copay per day for days 21-100 
•Your plan covers up to 100 days in aSNF 
Physical Therapy  
Cost share may vary depending 
on the service and where service 
is provided. •$15 to  $30 copay 
ADDITIONAL BENEFITS 
Ambulance (ground) $250  copay per date of service 
Ambulance (air) 20% of the cost 
Transportation $0 copay for plan approved location up to 24 one-way trip(s) per year. 
The member  must  contact transportation vendor to arrange 
transportation. 2022 - 10 - Summary of Benefits H1036265001