Cardiac rehabilitation $10 copay 30% of the cost 
Pulmonary rehabilitation $10 copay 30% of the cost 
TELEHEALTH SERVICES (in addition to Original Medicare) 
Primary care provider (PCP) $0 copay Not Covered 
Specialist $40 copay Not Covered 
Urgent care services $0 copay Not Covered 
Substance abuse or behavioral 
health services $0 copay Not Covered H5216107000SB23 Summary of Benefits 17 H5216107000 
More benefits with  your plan 
Enjoy some of these extra benefits included in your plan .