•Cardiac rehabilitation:  $25 copay 
•Pulmonary rehabilitation:  $25 copay 
Telehealth services 
(in addition to Original 
Medicare) •Primary care provider (PCP):  $0 copay 
•Specialist:  $25 copay 
•Urgent care services:  $0 copay 
•Substance abuse and behavioral health services:  $0 copay 2022 - 14 - Summary of Benefits H1036265001 
More benefits with  your plan 
Enjoy some of these extra benefits included in your plan .
COVID-19 Testing and Treatment 
$0 copay for testing and treatment