| Abortion for Which Public Funding is Prohibited | No charge |
| Accidental Dental | 20.00% Coinsurance after deductible |
| Acupuncture | $5.00 |
| Allergy Testing | 20.00% Coinsurance after deductible |
| Chemotherapy | $120.00 Copay after deductible |
| Chiropractic Care | $5.00 |
| Cosmetic Surgery | 20.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care | $425.00 Copay after deductible |
| 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 | $175.00 |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | 20.00% Coinsurance after deductible |
| Habilitation Services | $20.00 |
| Hearing Aids | 20.00% |
| Hearing Exams | 20.00% |
| Home Health Care Services | $10.00 |
| Hospice Services | $10.00 |
| Imaging (CT/PET Scans, MRIs) | 20.00% Coinsurance 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 after deductible |
| Laboratory Outpatient and Professional Services | $20.00 |
| Nutritional Counseling | No charge |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $5.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $325.00 Copay after deductible |
| Outpatient Rehabilitation Services | $20.00 |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 20.00% Coinsurance after deductible |
| Radiation | $120.00 Copay after deductible |
| Reconstructive Surgery | $425.00 Copay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $20.00 |
| Rehabilitative Speech Therapy | $20.00 |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | 20.00% Coinsurance after deductible |
| Skilled Nursing Facility | $425.00 Copay per Day after deductible |
| Substance Abuse Disorder Inpatient Services | $425.00 Copay per Day after deductible |
| Substance Abuse Disorder Outpatient Services | $5.00 |
| Transplant | $425.00 Copay after deductible |
| Treatment for Temporomandibular Joint Disorders | 20.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $30.00 |