IN-NETWORK OUT-OF-NETWORK 
PHYSICAL THERAPY 
Cost share may vary depending 
on the service and where service 
is provided. $20 to  $40 copay 30% of the cost 
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 
Prescription Drug Benefits 
PRESCRIPTION DRUGS 
Important Message About What You Pay for Vaccines