| Accidental Dental | No charge |
| Acquired Brain Injury | No charge |
| Acupuncture | Not covered |
| Allergy Testing | No charge |
| Hearing Aids | No charge |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | No charge |
| Substance Abuse Disorder Inpatient Services | No charge |
| Substance Abuse Disorder Outpatient Services | No charge |
| Transplant | No charge |
| Treatment for Temporomandibular Joint Disorders | No charge |
| Weight Loss Programs | Not covered |
| Weight Loss Treatment | No charge |
| Well Baby Visits and Care | No charge |
| Well Child Care | No charge |
| X-rays and Diagnostic Imaging | No charge |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Applied Behavior Analysis Based Therapies | No charge |
| Bariatric Surgery | No charge |
| Basic Dental Care - Adult | 50.00% |
| Basic Dental Care - Child | Not covered |
| Biomarke | No charge |
| Cardiac Rehabilitation | No charge |
| Chemotherapy | No charge |
| Chiropractic Care | No charge |
| Cochlear Implants | No charge |
| Community Health Worke | No charge |
| Cosmetic Surgery | Not covered |
| Craniofacial Surgery | No charge |
| Delivery and All Inpatient Services for Maternity Care | No charge |
| Dental Anesthesia | No charge |
| Dental Check-Up for Children | Not covered |
| Diabetes Care Management | No charge |
| Diabetes Education | No charge |
| Dialysis | No charge |
| Doulas | No charge |
| Durable Medical Equipment | No charge |
| Emergency Transportation/Ambulance | No charge |
| Eye Glasses for Children | No charge |
| Gastric Electrical Stimulation | No charge |
| Habilitation Services | No charge |
| Home Health Care Services | No charge |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | No charge |
| Infertility Treatment | No charge |
| Infusion Therapy | No charge |
| Inherited Metabolic Disorder - PKU | No charge |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | No charge |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | 50.00% |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | No charge |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | No charge |
| Outpatient Rehabilitation Services | No charge |
| PANS-PANDA | No charge |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | No charge |
| Radiation | No charge |
| Reconstructive Surgery | No charge |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | No charge |
| Rehabilitative Speech Therapy | No charge |
| Restorative Reproductive Treatment | No charge |
| Routine Dental Services (Adult) | No charge |
| Routine Eye Exam (Adult) | No charge |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | No charge |
| Skilled Nursing Facility | No charge |