| Abortion for Which Public Funding is Prohibited | No charge |
| Accidental Dental | $500.00 Copay after deductible |
| Acupuncture | $20.00 |
| Allergy Testing | $30.00 |
| Bariatric Surgery | $1000.00 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 | $1000.00 Copay per Stay after deductible |
| Dental Check-Up for Children | No charge |
| Diabetes Education | $30.00 |
| Dialysis | No charge |
| Durable Medical Equipment | 20.00% |
| Emergency Transportation/Ambulance | $100.00 Copay after deductible |
| Eye Glasses for Children | No charge |
| Habilitation Services | $30.00 Copay after deductible |
| Hearing Aids | No charge |
| Home Health Care Services | No Charge after deductible |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | $1000.00 Copay after deductible |
| Infertility Treatment | $1000.00 Copay after deductible |
| Infusion Therapy | No Charge after deductible |
| Inpatient Physician and Surgical Services | No Charge after deductible |
| Laboratory Outpatient and Professional Services | $30.00 |
| Major Dental Care - Child | 50.00% Coinsurance after deductible |
| Massage | No charge |
| Nutritional Counseling | No charge |
| Orthodontia - Child | 50.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $15.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $1000.00 Copay after deductible |
| Outpatient Rehabilitation Services | $30.00 Copay after deductible |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 20.00% |
| Radiation | No Charge after deductible |
| Reconstructive Surgery | $1000.00 Copay per Stay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $30.00 Copay after deductible |
| Rehabilitative Speech Therapy | $30.00 Copay after deductible |
| Routine Eye Exam (Adult) | No charge |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $30.00 |
| Skilled Nursing Facility | $1000.00 Copay per Stay after deductible |
| Substance Abuse Disorder Inpatient Services | $1000.00 Copay per Stay after deductible |
| Substance Abuse Disorder Outpatient Services | $15.00 |
| Transplant | $1000.00 Copay per Stay after deductible |
| Treatment for Temporomandibular Joint Disorders | $1000.00 Copay after deductible |
| Weight Loss Programs | No charge |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $50.00 Copay after deductible |