on where service is provided. $0 copay or  10% to  20% of the 
cost 30% of the cost 16 Summary of Benefits H5216107000SB23 H5216107000 
REHABILITATION SERVICES 
Occupational and speech 
therapy 
Cost share may vary depending 
on the service and where service 
is provided. $20 to  $40 copay 30% of the cost 
Cardiac rehabilitation $10 copay 30% of the cost 
Pulmonary rehabilitation $10 copay 30% of the cost 
TELEHEALTH SERVICES (in addition to Original Medicare)