MEDICAL EQUIPMENT/SUPPLIES 
Durable medical equipment (like 
wheelchairs or oxygen) 20% of the cost 30% of the cost 
Medical Supplies 20% of the cost 20% of the cost 
Prosthetics (artificial limbs or 
braces) 20% of the cost 30% of the cost 
Diabetic monitoring supplies 
Cost share may vary depending 
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