through mail order) reach  $7,4 00 you pay the greater of: 
•5% of the cost, or 
•$4.15 copay for generic (including brand drugs treated as generic) and a  $10.35 copay for all other 
drugs 
Additional Benefits 
Medicare-covered foot care 
(podiatry) $15 copay 
Medicare-covered chiropractic 
services $20 copay 
Medical equipment/ supplies 
Cost share may vary depending 
on the service and where service 
is provided •Durable medical equipment (like wheelchairs or oxygen):  20% of 
the cost