| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 15.00% Coinsurance after deductible |
| Abortion for Which Public Funding is Prohibited | 15.00% Coinsurance after deductible |
| Accidental Dental | 15.00% Coinsurance after deductible |
| Allergy Testing | 15.00% Coinsurance after deductible |
| Chemotherapy | 15.00% Coinsurance after deductible |
| Chiropractic Care | 15.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care | 15.00% Coinsurance after deductible |
| Diabetes Education | No charge |
| Dialysis | 15.00% Coinsurance after deductible |
| Durable Medical Equipment | 15.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 15.00% Coinsurance after deductible |
| Eye Glasses for Children | 15.00% Coinsurance after deductible |
| Habilitation Services | 15.00% Coinsurance after deductible |
| Hearing Aids | 15.00% Coinsurance after deductible |
| Home Health Care Services | 15.00% Coinsurance after deductible |
| Hospice Services | 15.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 15.00% Coinsurance after deductible |
| Infusion Therapy | 15.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 15.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 15.00% Coinsurance after deductible |
| Nutritional Counseling | No charge |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | 15.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 15.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | 15.00% Coinsurance after deductible |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 15.00% Coinsurance after deductible |
| Radiation | 15.00% Coinsurance after deductible |
| Reconstructive Surgery | 15.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | 15.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy | 15.00% Coinsurance after deductible |
| Routine Eye Exam for Children | No charge |
| Skilled Nursing Facility | 15.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 15.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | 15.00% Coinsurance after deductible |
| Transplant | 15.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 15.00% Coinsurance after deductible |