•Pulmonary rehabilitation:  $10 copay 
Telehealth services 
(in addition to Original 
Medicare) •Primary care provider (PCP):  $0 copay 
•Specialist:  $15 copay 
•Urgent care services:  $0 copay 
•Substance abuse and behavioral health services:  $0 copay H1036236000SB23 Summary of Benefits 15 H1036236000 
More benefits with  your plan 
Enjoy some of these extra benefits included in your plan . 
This is asummary of what we cover. It doesn't list every service that we cover or list