| Orthodontia - Child | 50.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $20.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $250.00 Copay after deductible |
| Outpatient Rehabilitation Services | $45.00 |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 20.00% Coinsurance after deductible |
| Radiation | No Charge after deductible |
| Reconstructive Surgery | $500.00 Copay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $45.00 |
| Rehabilitative Speech Therapy | $45.00 |
| Routine Eye Exam (Adult) | No charge |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $45.00 |
| Skilled Nursing Facility | $500.00 Copay per Stay after deductible |
| Substance Abuse Disorder Inpatient Services | $500.00 Copay per Stay after deductible |
| Substance Abuse Disorder Outpatient Services | $20.00 |
| Transplant | $500.00 Copay after deductible |
| Treatment for Temporomandibular Joint Disorders | $250.00 Copay after deductible |
| Weight Loss Programs | No charge |
| Well Baby Visits and Care | No charge |
| Abortion for Which Public Funding is Prohibited | No charge |
| Accidental Dental | $250.00 Copay after deductible |
| Acupuncture | $20.00 |
| Allergy Testing | $45.00 |
| Bariatric Surgery | $250.00 Copay after deductible |
| Basic Dental Care - Child | 25.00% Coinsurance after deductible |
| Chemotherapy | No Charge after deductible |
| Chiropractic Care | $20.00 |
| Delivery and All Inpatient Services for Maternity Care | $500.00 Copay after deductible |
| Dental Check-Up for Children | No charge |
| Diabetes Education | $45.00 |
| Dialysis | No charge |
| Durable Medical Equipment | 20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | No charge |
| Eye Glasses for Children | No charge |
| Habilitation Services | $45.00 |
| Hearing Aids | No charge |
| Home Health Care Services | No charge |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | $200.00 Copay after deductible |
| Infertility Treatment | $250.00 Copay after deductible |
| Infusion Therapy | No Charge after deductible |
| Inpatient Physician and Surgical Services | No Charge after deductible |
| Laboratory Outpatient and Professional Services | $25.00 Copay after deductible |
| Major Dental Care - Child | 50.00% Coinsurance after deductible |
| Massage | No charge |
| Nutritional Counseling | No charge |
| X-rays and Diagnostic Imaging | $35.00 Copay after deductible |