•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 
IN-NETWORK OUT-OF-NETWORK 
Medicare-covered foot care 
(podiatry) $30 copay $30 copay 
Medicare-covered chiropractic 
services $20 copay $20 copay 
MEDICAL EQUIPMENT/SUPPLIES 
Durable medical equipment (like 
wheelchairs or oxygen) 20% of the cost 20% of the cost 
Medical Supplies 20% of the cost 20% of the cost 
Prosthetics (artificial limbs or