on where service is provided. $0 copay or  10% to  20% of the 
cost 10% to  20% of the cost 
REHABILITATION SERVICES 
Occupational and speech 
therapy 
Cost share may vary depending 
on the service and where service 
is provided. $20 to  $30 copay $20 to  $30 copay 
Cardiac rehabilitation $10 copay $10 copay H5216324000SB23 Summary of Benefits 17 H5216324000 
Pulmonary rehabilitation $10 copay $10 copay 
TELEHEALTH SERVICES (in addition to Original Medicare)