Cardiac rehabilitation $10 copay $10 copay H5216324000SB23 Summary of Benefits 17 H5216324000 
Pulmonary rehabilitation $10 copay $10 copay 
TELEHEALTH SERVICES (in addition to Original Medicare) 
Primary care provider (PCP) $0 copay Not Covered 
Specialist $30 copay Not Covered 
Urgent care services $0 copay Not Covered 
Substance abuse or behavioral 
health services $0 copay Not Covered 18 Summary of Benefits H5216324000SB23 H5216324000 
More benefits with  your plan