| Reconstructive Surgery | No charge |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 25.00% Coinsurance after deductible |
| Acupuncture | Not covered |
| Allergy Testing | No charge |
| Bariatric Surgery | 25.00% Coinsurance after deductible |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | 25.00% Coinsurance after deductible |
| Chemotherapy | 25.00% Coinsurance after deductible |
| Chiropractic Care | $30.00 |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 25.00% Coinsurance after deductible |
| Dental Check-Up for Children | No charge |
| Diabetes Education | No charge |
| Dialysis | 25.00% Coinsurance after deductible |
| Durable Medical Equipment | 25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 25.00% Coinsurance after deductible |
| Eye Glasses for Children | 50.00% |
| Habilitation Services | $30.00 |
| Hearing Aids | 25.00% Coinsurance after deductible |
| Home Health Care Services | 25.00% Coinsurance after deductible |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | 25.00% Coinsurance after deductible |
| Infertility Treatment | $60.00 |
| Infusion Therapy | 25.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | 25.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | 25.00% Coinsurance after deductible |
| Nutritional Counseling | 0.00% |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | 25.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | No charge |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 25.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | 25.00% Coinsurance after deductible |
| Prenatal and Postnatal Care | 25.00% Coinsurance after deductible |
| Private-Duty Nursing | No charge |
| Prosthetic Devices | Not covered |
| Radiation | 25.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $30.00 |
| Rehabilitative Speech Therapy | $30.00 |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | $0.00 |
| Routine Foot Care | No charge |
| Sex-Trait Modification | 25.00% Coinsurance after deductible |
| Skilled Nursing Facility | 25.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 25.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $30.00 |
| Transplant | 25.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | $60.00 |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 25.00% Coinsurance after deductible |