| Abortion for Which Public Funding is Prohibited | No charge |
| Acupuncture | $15.00 |
| Allergy Testing | 20.00% Coinsurance after deductible |
| Chemotherapy | $75.00 Copay after deductible |
| Chiropractic Care | $15.00 |
| Cosmetic Surgery | 20.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care | $525.00 |
| Dental Anesthesia | 20.00% Coinsurance after deductible |
| Diabetes Care Management | No charge |
| Diabetes Education | No charge |
| Dialysis | 20.00% Coinsurance after deductible |
| Durable Medical Equipment | 20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | $375.00 |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | 20.00% Coinsurance after deductible |
| Habilitation Services | $25.00 |
| Hearing Aids | 20.00% |
| Hearing Exams | 20.00% |
| Home Health Care Services | $15.00 |
| Hospice Services | $15.00 |
| Imaging (CT/PET Scans, MRIs) | $300.00 Copay after deductible |
| Infertility Treatment | 20.00% Coinsurance after deductible |
| Infusion Therapy | 20.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU | 20.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | $30.00 |
| Nutritional Counseling | No charge |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $15.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $350.00 Copay after deductible |
| Outpatient Rehabilitation Services | $25.00 |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 20.00% Coinsurance after deductible |
| Radiation | $75.00 Copay after deductible |
| Reconstructive Surgery | $525.00 |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $25.00 |
| Rehabilitative Speech Therapy | $25.00 |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | 20.00% Coinsurance after deductible |
| Skilled Nursing Facility | $350.00 Copay per Day after deductible |
| Substance Abuse Disorder Inpatient Services | $525.00 Copay per Day |
| Substance Abuse Disorder Outpatient Services | $15.00 |
| Transplant | $525.00 |
| Treatment for Temporomandibular Joint Disorders | 20.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $30.00 |