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 
•Medical supplies:  20% of the cost 
•Prosthetics (artificial limbs or braces):  20% of the cost 
•Diabetic monitoring supplies:  $0 copay or  10% to  20% of the cost 
Rehabilitation services •Occupational and speech therapy:  $15 copay 
•Cardiac rehabilitation:  $0 copay