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in -Network <br />Ambulance $200 copay for each <br />Medicare -covered trip (one-way) 0 <br />Out -of -Network <br />■ $200 for each Medicare- covered <br />trip (one-way) <br />Transportation ■ Not Covered ■ Not Covered <br />Medicare Part B ■ $0 Copay copay for allergy <br />Drugs injections <br />■ Up to 20% of the <br />Medicare -allowed amount for <br />chemotherapy drugs and other <br />Medicare Part B -covered drugs 0 <br />■ 20% up to $35 per month for <br />insulin if you use an insulin pump <br />that's covered under Part B's <br />durable medical equipment <br />benefit 0 <br />■ 40% of the Medicare -allowed <br />amount after $2,000 <br />out -of -network deductible <br />Additional Benefits <br />`lei-Netir-jor <br />Out-of-Networ <br />f (y <br />Diabetic Supplies $0 copay at a Florida Blue <br />40% of the Medicare -allowed <br />Medicare contracted network <br />amount after $2,000 <br />retail or mail-order pharmacy for <br />out -of -network deductible <br />Diabetic Supplies such as: <br />0 Lifescan (One Touch@) <br />and Ascensia (Contour <br />@) glucose meters and <br />test strips are <br />preferred. Other <br />brands will require <br />prior authorization 0 <br />• Lancets <br />11 <br />