| Other Practitioner Office Visit (Nurse, Physician Assistant) | $5.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 15.00% |
| Osteoporosis | 15.00% |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 15.00% |
| Acupuncture | Not covered |
| Allergy Testing | $10.00 |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Bone Marrow Transplant | 15.00% |
| Cardiac Rehabilitation | 15.00% |
| Chemotherapy | 15.00% |
| Child Health Supervision | No charge |
| Chiropractic Care | $10.00 |
| Congenital Anomaly, including Cleft Lip/Palate | 15.00% |
| Contraceptive Injections | 15.00% |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 15.00% |
| Dental Anesthesia | 15.00% |
| Dental Check-Up for Children | Not covered |
| Diabetes Care Management | 15.00% |
| Diabetes Education | No charge |
| Dialysis | 15.00% |
| Durable Medical Equipment | 50.00% |
| Emergency Transportation/Ambulance | 15.00% |
| Enteral Formulas | 15.00% |
| Eye Glasses for Children | No charge |
| Habilitation Services | 15.00% |
| Hearing Aids | Not covered |
| Home Health Care Services | 15.00% |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | 15.00% |
| Infertility Treatment | Not covered |
| Infusion Therapy | 15.00% |
| Inpatient Physician and Surgical Services | 15.00% |
| Laboratory Outpatient and Professional Services | 15.00% |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Mammogram | No charge |
| Mastectomy | 15.00% |
| Nutritional Counseling | No charge |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Orthotic Devices | 50.00% |
| Outpatient Rehabilitation Services | 15.00% |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | 50.00% |
| Pulmonary Rehabilitation | 15.00% |
| Radiation | 15.00% |
| Reconstructive Surgery | 15.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | 15.00% |
| Rehabilitative Speech Therapy | 15.00% |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $10.00 |
| Skilled Nursing Facility | 15.00% |
| Substance Abuse Disorder Inpatient Services | 15.00% |
| Substance Abuse Disorder Outpatient Services | $5.00 |
| Transplant | 15.00% |
| Treatment for Temporomandibular Joint Disorders | 15.00% |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 15.00% |